Posts Tagged Medicare

Medical Association Signs on to Letter Targeting PA Requirements

Medical Association Signs on to Letter Targeting PA Requirements

The Medical Association recently joined the American Medical Association and 85 other national medical groups and state medical associations in sending a letter to the Centers for Medicare & Medicaid  Services to urge CMS to provide guidance to Medicare Advantage plans on prior authorization processes through its 2020 Call Letter. In the jointly signed letter, the groups call upon CMS to require MA plans to selectively apply PA requirements and provide examples of criteria to be used for programs such as ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates. Citing the CMS Patients Over Paperwork initiative, the letter stresses this new guidance will promote safe, timely and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.

The letter further explains how the prior authorization process has been found to be burdensome for health care providers, health plans and even patients and that physicians and insurers have agreed that these policy changes to eliminate PAs on those services for which there is low variation in care can promote greater transparency regarding services subject to PAs and protect patients to ensure PAs do not impact the continuity of care.

PA programs can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes. According to a 2018 AMA survey of 1,000 practicing physicians, 91 percent of physicians said PAs can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 91 percent indicated that PA can have a negative impact on patient clinical outcomes. Most alarmingly, 28 percent of physicians indicated that PA has led to a serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage) for a patient in their care.

Read the letter in its entirety

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Navigate the New Medicare ID Transition in Nine Steps

Navigate the New Medicare ID Transition in Nine Steps

Due to a legislative mandate in MACRA passed in 2015, Medicare will no longer use Social Security numbers to identify individuals. Instead, a new randomly generated Medicare Beneficiary Identifier (MBI) will be assigned to all 58 million Medicare recipients. New Medicare ID cards containing the MBI are currently being sent to recipients.

The MBI replaces the Health Insurance Claim Number (HICN) used for Medicare transactions like billing, eligibility status, and claim status. Whereas the HICN started with the 10-digit Social Security number and ended with a letter or two designating a policy type, the 11-digit MBI will contain both letters and numbers throughout.

The transition to these new cards is a big step for patients as well as providers, and all stakeholders must be ready to accept, receive and transmit the new MBI.

Make the Transition in Nine Easy Steps

  • Educate practice staff about the rollout of the new Medicare cards with the new MBIs.
  • Contact practice-management system vendors about what system changes need to be made to accommodate the MBIs.
  • Alert your Medicare patients that they will be receiving new Medicare cards with their new MBIs.
  • Remind Medicare patients to confirm the Social Security Administration has their correct address on file to ensure they receive their new Medicare cards.
  • Tell Medicare patients to bring their new Medicare cards to their next appointment after they receive it.
  • Begin using the new MBI in Medicare transactions as soon as it is available for the patient.
  • Monitor eligibility responses for messages that indicate the patient was mailed a new Medicare card.
  • Starting Oct. 1, 2018, monitor remittance advices for messages that provide the patient’s MBI.
  • Sign up for the MBI look-up tool via your regional MAC portal.

For more information, log on to www.cms.gov and click the Medicare tab.

Posted in: Medicare

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Brookwood Baptist Medical Center Medicare Certification Extended

Brookwood Baptist Medical Center Medicare Certification Extended

Brookwood Baptist Medical Center, the second largest hospital in the metro Birmingham area, received an 11th-hour reprieve Thursday night with regulators from the Centers for Medicare and Medicaid Services accepted the facility’s action, thus allowing the hospital to continue its Medicare and Medicaid billing privileges. However, the facility is not out hot water just yet.

“The immediate jeopardies have been removed at this time, but the hospital remains in noncompliance status and must work to correct the deficiencies cited to protect the health and safety of the facility’s patients,” according to a CMS statement, which also noted the survey review process can be extended over the next 60 days.

Brookwood Baptist CEO Keith Parrott said the hospital will continue to fully participate in the Medicare and Medicaid programs without further interruption. Even a short-term interruption in participation could pose a significant financial challenge given the large amount of revenue and jobs at stake. Parrott also said the hospital will be resurveyed in the future.

In May, Brookwood Baptist received a notice stemming from an April incident in its psychiatric unit. The May CMS order was rescinded after a follow-up inspection determined Brookwood Baptist was in compliance with guidelines. Brookwood Baptist received a termination notice in late July that gave the hospital until Aug. 9 to become compliant with CMS guidelines pertaining to government body, patients’ rights and nursing services.

It was the second notice the hospital has received this year.

According to CMS, Brookwood’s immediate jeopardy notice was based on “the hospital’s failure to staff to implement its elopement policy resulting in the death of one patient; failure of staff in the telemetry monitoring unit to notify registered nurses of a patient who had no heart rate for 15 minutes and subsequently died; and a failure of staff to notify the physician of a patient’s low blood pressure readings resulting in the patient being found unresponsive and not breathing.

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CMS Publishes 2019 Physician Fee Schedule

CMS Publishes 2019 Physician Fee Schedule

UPDATED JULY 27, 2018: CMS Overhauls Office Visit Pay In Proposed 2019 Physician Fee Rule

CMS is proposing to overhaul how Medicare pays for office visits and how doctors document those visits in what Administrator Seema Verma said would be “one of the most significant reductions in provider burden ever taken by any administration.” The change, which is included in the proposed 2019 Physician Fee Schedule released Thursday, July 12, would simplify coding and create a single payment amount for “evaluation and management” visits, or E/M visits, and some specialists could see payment reductions as a result. The Medical Association is continuing to analyze the proposed fee schedule to see what potential impact it will have on physician practices in Alabama. We will keep you posted as more information becomes available.

In what industry lobbyists said would be another significant change, the proposed rule also seeks to establish new payment codes for two new virtual services: telephone “check-ins” between clinicians and beneficiaries, and the remote evaluation of photos or videos that a patient submits to a clinician.

In addition, the proposed rule would enact provisions of the Bipartisan Budget Act of 2018 to expand telehealth services for beneficiaries with end-stage renal disease receiving home dialysis and beneficiaries with acute stroke. CMS was expected to use its 2019 pay rules to expand telehealth in Medicare.

Verma touted the proposed overhaul of the E/M payment system as a way to reduce the time that doctors spend “copying, pasting, and clicking” to comply with the current system’s onerous documentation requirements.

“Doctors should not be spending time typing in information strictly to bill a certain level of code,” Verma said on a conference call with reporters.

The proposed rule would change the current system, which has four sets of documentation requirements for physicians, to a system with a single set of documentation requirements. It would establish a single, blended rate for E/M visits–a change that Verma said could result in a 1-2 percent pay reduction for doctors who typically bill at the higher rates under the existing system.

“We believe any negative payment adjustments will be outweighed by the dramatic reduction in administrative burden, allowing clinicians more time to spend with their patients,” Verma said.

The proposed rule also retains a so-called site-neutral policy under which certain off-campus hospital outpatient departments are paid 40 percent of what they would have received under the Hospital Outpatient Prospective Payment System. The American Hospital Association released a statement calling that portion of the proposed rule short-sighted.

The proposed rule includes a request for information on how CMS could make health care costs more transparent. In the 2019 Hospital Inpatient Prospective Payment System proposed rule, CMS said it would require hospitals to post their standard charges online, but the agency said Thursday that it thinks more can be done on price transparency and is seeking suggestions from the public on how it can better inform patients about out-of-pocket costs.

Other provisions in the proposed rule include:

  • Reducing the level of physician supervision required for services provided by radiologist assistants.
  • Allowing payment for communication technology-based services and remote evaluation services furnished by rural health clinics and federally qualified health centers.
  • Discontinuing functional status reporting requirements for outpatient therapy.
  • Implementing a statutory pay reduction for services provided by therapy assistants.
  • Seeking comments on how to combat opioid use disorder in Medicare.

The proposed rule’s conversion factor, a value used in CMS’ formula to calculate payment rates, is $36.05, up from the 2018 conversion factor of $35.99. Public comments on the proposed rule are due Sept. 10.


CMS has published the proposed Physician Fee Schedule Rule for 2019, which includes provisions for the Quality Payment Program for 2019 as well as the physician fee schedule. Medical Association staff is reviewing the proposed rule and would appreciate any comments you might have concerning its contents.

This is a brief summary of the key Medicare Fee Schedule proposals:

  • With the budget neutrality adjustment to account for relative value changes, as required by law, the proposed 2019 PFS conversion factor is $36.05, a slight increase above the 2018 PFS conversion factor of $35.99.
  • CMS has proposed to collapse payment for office and outpatient visits.  New patient office visit (99202-99205) payments would be blended to be $135. Established office visits (99212-99215) would be blended to be paid at $93. New codes would be created to provide add-on payments to office visits for specific specialties ($9) and primary care physicians ($5).
  • To replace existing documentation guidelines, CMS proposes to allow use of (1) 1995 or 1997 documentation guidelines; (2) medical decision-making or (3) time. Documentation for history and exam will focus on interval history since last visit. Physicians will be allowed to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering the information.
  • When physicians report an E/M service and a procedure on the same date, CMS proposes to implement a 50% multiple procedure reduction to the lower paid of the two services.
  • CMS will implement new CPT codes and payment for remote monitoring and interprofessional consultations.
  • CMS updated supplies and equipment pricing. The re-pricing of antigens has a significant impact on allergy and immunology payments, with an estimated 6% reduction for the specialty.

Here are some of the highlights of the Merit-based Incentive Payment System (MIPS) proposals:

  • Retain the low-volume threshold but add a third criteria of providing fewer than 200 covered professional services to Part B patients.
  • Retaining bonus points for: care of complex patients, end-to-end reporting, small practices
  • Allowing eligible clinicians to opt-in if they meet one or two, but not all, of the low volume threshold criterion.
  • Consolidating the low-volume threshold determination periods with the determination period for identifying a small practice.
  • Eliminate the base and performance categories and reduced the number of measures in the Promoting Interoperability category.
  • Require Eligible clinicians to move to 2015 CEHRT.
  • Providing the option to use facility-based scoring for facility-based clinicians.
  • For 2019 performance year the weights are: Quality  – 45%; Cost- 15%; Promoting Interoperability – 25%; Improvement Activities- 15%

As a reminder, the Bipartisan Budget Act of 2018 provided additional flexibility for CMS on several MIPS issues including:

  • Excluding Medicare Part B drug costs from MIPS payment adjustments and from the low-volume threshold determination;
  • Allowing CMS to reweight the cost performance category to not less than 10 percent and not more than 30 percent for 2019-2021 performance years; and
  • Allowing CMS flexibility in setting the performance threshold for performance years 2019-2021 to provide a gradual and incremental transition for physicians.

 

 

 

 

CMS has provided Fact Sheets on the major components of the rule which are available at the following links:

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-QPP-proposed-rule-fact-sheet.pdf .

In addition, the specialty impact table from the rule is attached for your information.

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Trump Administration Releases Drug Pricing Blueprint

Trump Administration Releases Drug Pricing Blueprint

On May 11, The Trump Administration released “American Patients First,” the President’s blueprint to lower drug prices and reduce out-of-pocket costs, along with a request for information. The Blueprint was framed as advancing four specific goals:

  • Reducing list prices;
  • Improving government’s ability to negotiate better prices;
  • Encouraging competition through rapid entry to market of generics and biosimilars; and
  • Lowering patient out-of-pocket expenses.

The Blueprint proposes a broad number of changes to prescription drug programs in several federal health care programs – such as Medicare, Medicaid and other safety net programs – as well as Food and Drug Administration policies that should impact commercial and federal health care program access to affordable prescription drugs.

While some of these proposals can be undertaken through immediate regulatory or subregulatory actions, others are still on the drawing boards at the U.S. Department of Health and Human Services and some will require congressional action to implement. The Blueprint proposes a select number of programmatic and design changes, yet the Administration is seeking feedback for a large number of lingering questions.

Initial review appears to show an increased access to lower-cost alternative generics. But closer review is needed on proposed changes to the Medicare Part D Prescription Drug Benefit Program and the Part B drug reimbursement methods to alleviate concerns the changes may limit patient access to medically necessary alternative brand or specialty treatments and result in additional administrative burdens on physicians and patients. The proposal may also eliminate the requirement that Part D plans include a minimum of two drugs proven to be effective in each therapeutic category or pharmacologic class, if available.

The Medical Association will be closely monitoring the Administration’s “American Patients First” Blueprint and will keep our members updated on any new developments as they become available.

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CMS Issues Final Rule on 2018 Medicare Reimbursement

CMS Issues Final Rule on 2018 Medicare Reimbursement

The Centers for Medicare & Medicaid Services has issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2018.

Background on the Physician Fee Schedule

Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service. These services include but are not limited to, visits, surgical procedures, diagnostic tests, therapy services and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service. Relative Value Units (RVUs) are applied to each service for work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute.

Patients Over Paperwork

CMS recently launched the “Patients Over Paperwork” Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience. This effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients. The Medicare Physician Fee Schedule final rule includes the following as part of this initiative:

  • reducing reporting requirements
  • removing downward payment adjustments based on performance for practices that meet minimum quality reporting requirements 

Payment Provisions 

Changes in Valuation for Specific Services

CMS reviews the resource inputs for several hundred codes under the annual process referred to as the potentially misvalued code initiative. Recommendations from the American Medical Association-Relative Value Scale Update Committee (RUC) are critically important to this work. For CY 2018, CMS is finalizing the values for individual services that generally reflect the expert recommendations from the RUC without as many refinements as CMS made in recent years.

Overall Payment Update and Misvalued Code Target

The overall update to payments under the PFS based on the finalized CY 2018 rates will be +0.41 percent. This update reflects the +0.50 percent update established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by 0.09 percent, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience (ABLE) Act of 2014.

After applying these adjustments, and the budget neutrality adjustment to account for changes in RVUs, all required by law, the final 2018 PFS conversion factor is $35.99, an increase to the 2017 PFS conversion factor of $35.89.

Payment Rates for Nonexcepted Off-campus Provider-Based Hospital Departments Paid Under the PFS

Section 603 of the Bipartisan Budget Act of 2015 requires that certain items and services furnished by certain off-campus hospital outpatient provider-based departments are no longer paid under the OPPS beginning Jan. 1, 2017. For CY 2017, CMS finalized the PFS as the applicable payment system for most of these items and services.

For CY 2018, CMS is finalizing a reduction to the current PFS payment rates for these items and services by 20 percent. CMS currently pays for these services under the PFS based on a percentage of the OPPS payment rate. Specifically, the final policy will change the PFS payment rates for these services from 50 percent of the OPPS payment rate to 40 percent of the OPPS rate. CMS believes this adjustment will provide a more level playing field for competition between hospitals and physician practices by promoting greater payment alignment.

Medicare Telehealth Services

For CY 2018, CMS is finalizing the addition of several codes to the list of telehealth services, including:

  • HCPCS code G0296 (visit to determine low dose computed tomography (LDCT) eligibility);
  • CPT code 90785 (Interactive Complexity);
  • CPT codes 96160 and 96161 (Health Risk Assessment);
  • HCPCS code G0506 (Care Planning for Chronic Care Management); and
  • CPT codes 90839 and 90840 (Psychotherapy for Crisis).

CMS is finalizing its proposal to eliminate the required reporting of the telehealth modifier GT for professional claims in an effort to reduce administrative burden for practitioners and finalizing separate payment for CPT code 99091, which describes certain remote patient monitoring, for CY 2018.

In the proposed rule, CMS sought comment on whether to make separate payment for CPT codes that describe remote patient monitoring or other existing codes that describe extensive use of communications technology. Some commenters raised concerns with our proposal, citing concerns that existing CPT codes were overly broad and not always reflective of current technology. Other commenters were supportive of the proposal generally but noted that CPT is currently working on codes that more accurately describe remote patient monitoring. In the final rule, CMS is finalizing separate payment for CPT code 99091 (Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, for 2018 pending anticipated changes in CPT coding.

Malpractice Relative Value Units (RVUs)

For CY 2017, CMS collected updated professional liability insurance data for the purposes of updating the malpractice geographic practice cost indices but did not propose to use the data to update the specialty risk factors used in the calculation of malpractice RVUs at that time. Rather, CMS solicited comment on whether it should consider updating the malpractice RVUs based on the updated professional liability insurance data prior to the next expected 5-year update (CY 2020).

After consideration of public comments received, for CY 2018, CMS is not finalizing its proposal to develop malpractice RVUs using the most recent data available. Implementation not finalizing the proposal to use premium data collected for the would occur by CY 2017 malpractice geographic practice cost indices to update the specialty risk factors for CY 2018-2020. Additionally, CMS is not finalizing the proposal to align the update of malpractice premium data with the malpractice geographic practice cost index updates, which has been done once every three years, at this time.

Care Management Services

CMS is continuing efforts to improve payment within traditional fee-for-service Medicare for chronic care management and similar care management services to accommodate the changing needs of the Medicare patient population. CMS is finalizing its proposals to adopt CPT codes for CY 2018 for reporting several care management services currently reported using Medicare G-codes and clarifying a few policies regarding chronic care management in this final rule.

Improvement of Payment Rates for Office-based Behavioral Health Services

CMS is finalizing an improvement in the way physician fee schedule rates are set that will positively impact office-based behavioral health services with a patient. The final policy will increase payment for these important services by better recognizing overhead expenses for office-based face-to-face services with a patient.

Evaluation and Management Comment Solicitation

Most physicians and other practitioners bill patient visits to the PFS under a relatively generic set of codes that distinguish level of complexity, site of care, and in some cases whether or not the patient is new or established, or Evaluation and Management (E/M) visit codes. Billing practitioners must maintain information in the medical record that documents they have reported the appropriate level of E/M visit code. CMS maintains guidelines that specify the kind of information that is required to support Medicare payment for each level.

CMS agreed with continued feedback from stakeholders that these guidelines are potentially outdated and need to be revised.

CMS thanks the public for the comments received in response to the proposed rule’s comment solicitation on the E/M guidelines and summarizes these comments in the final rule. Commenters suggested additional avenues for collaboration with stakeholders prior to implementing any changes, and CMS will consider the best approaches for such collaboration and will take the public comments into account for future rulemaking.

Emergency Department Visits Comment Solicitation

CMS sought comment from stakeholders on whether emergency department visits are undervalued due to increasing heterogeneity of the settings under which emergency department visits are furnished and changes to the patient population. A number of comments were received suggesting these services are potentially misvalued and will be reviewing emergency department visits (CPT codes 99281-99385) as potentially misvalued for future rulemaking.

Solicitation of Public Comments on Initial Data Collection and Reporting Periods for Clinical Laboratory Fee Schedule

The Clinical Laboratory Fee Schedule (CLFS) final rule entitled “Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System” implements Section 1834A of the Social Security Act (the Act), which requires extensive revisions to the Medicare payment, coding, and coverage for Clinical Diagnostic Laboratory Tests (CDLTs) paid under the CLFS. Under the final rule, the payment amount for a test on the CLFS furnished on or after Jan. 1, 2018, generally will be equal to the weighted median of private payer rates determined for the test, based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during a specified data reporting period. The first data collection period was from Jan. 1 through June 30, 2016, and the first data reporting period was from Jan. 1, 2017, through March 31, 2017.

Laboratory industry feedback suggested that many reporting entities would not be able to submit a complete set of applicable information to CMS by the March 31, 2017, deadline. As a result, on March 30, 2017, CMS announced a 60-day period of enforcement discretion until May 30, 2017, with respect to the data reporting period for reporting applicable information under the Medicare CLFS and the application of the Secretary’s potential assessment of civil monetary penalties (CMPs) for failure to report applicable information.

In the proposed rule, CMS solicited public comments from applicable laboratories and reporting entities to better understand applicable laboratories’ experiences with the data reporting, data collection, and other compliance requirements for the first data collection and reporting periods under the new private payor rate-based CLFS.

Part B Drugs: Payment for Biosimilar Biological Products

In the CY 2016 PFS final rule with comment period, CMS finalized a proposal to make clear that biosimilar products that rely on a common reference product’s biologics license application are grouped into the same payment calculation for determining a single average sales price payment limit, and that a single Healthcare Common Procedure Coding System (HCPCS) code is used for such biosimilar products.

In the CY 2018 PFS proposed rule, CMS asked for comments on the effects of its payment policy based on experience with the United States’ biosimilar product marketplace.

CMS received numerous comments on this issue. In response to concerns raised in the comments, CMS is changing the policy to separately code and pay for biological biosimilar products under Medicare Part B. Effective Jan. 1, 2018, newly approved biosimilar biological products with a common reference product will no longer be grouped into the same billing code.

CMS believes a solution that increases provider and patient choice is superior to existing policy and may lead to additional cost savings over the long-term. By encouraging innovation and greater manufacturer participation in the marketplace, this policy change will result in the licensing of more biosimilar products, creating a stable and robust market, driving competition and decreasing uncertainty about access and payment. Carrying out this policy change as early as possible, rather than waiting, is expected to bring more certainty to the new and developing marketplace.

Part B Drug Payment: Infusion Drugs Furnished through an Item of Durable Medical Equipment (DME)

The 21st Century Cures Act transitioned payment for infusion drugs or biologicals furnished through a covered item of DME from average wholesale price (AWP) to average sales price (ASP) pricing methodology on Jan. 1, 2017. CMS is finalizing the proposed revision to 42 CFR §414.904(e)(2) to conform regulations with the statutory payment requirements in section 5004(a) of the 21st Century Cures Act.

New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)

CMS is finalizing the proposal to revise payment for chronic care management in RHCs and FQHCs, and establish requirements and payment for RHCs and FQHCs furnishing general behavioral health integration (BHI) services and psychiatric collaborative care model (CoCM) services. Effective Jan. 1, 2018, RHCs and FQHCs will be paid for CCM, general BHI, and psychiatric CoCM using two new billing codes created exclusively for RHC and FQHC payment. This payment would be in addition to the payment for an RHC or FQHC visit.

Appropriate Use Criteria for Advanced Diagnostic Imaging

CMS is finalizing a start date for the Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging. The program will begin in a manner that allows practitioners more time to focus on and adjust to the Quality Payment Program before being required to participate in the AUC program. The Medicare AUC program will begin with an educational and operations testing year in 2020, which means physicians would be required to start using AUCs and reporting this information on their claims. During this first year, CMS is proposing to pay claims for advanced diagnostic imaging services regardless of whether they correctly contain information on the required AUC consultation. This allows both clinicians and the agency to prepare for this new program.

CMS posted newly qualified provider-led entities and clinical decision support mechanisms in July of this year. Qualified provider-led entities are permitted to develop AUC, and qualified clinical decision support mechanisms are the tools that physicians use to access the AUC. Physicians may begin exploring these mechanisms well in advance of the start of the Medicare AUC program through the voluntary participation period that will begin mid-2018 and run through 2019. During this time CMS will collect limited information on Medicare claims to identify advanced imaging services for which consultation with appropriate use criteria took place.

In addition, by having qualified clinical decision support mechanisms available (some of which are free of charge) clinicians may use one of these mechanisms to earn credit under the Merit-Based Incentive Payment System as an improvement activity. This improvement activity was included in the 2018 Quality Payment Program final rule.

Medicare Diabetes Prevention Program Expanded Model

The final rule also implements the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. The MDPP expanded model was announced in early 2016, when it was determined that the Diabetes Prevention Program (DPP) model test through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards met the statutory criteria for expansion. The final rule includes additional policies necessary for suppliers to begin furnishing MDPP services nationally in 2018, including the MDPP payment structure, as well as additional supplier enrollment requirements and supplier compliance standards aimed to enhance program integrity.

Physician Quality Reporting System (PQRS)

Under the PQRS, individual eligible professionals and group practices who did not satisfactorily report data on quality measures for the CY 2016 reporting period are subject to a downward payment adjustment of 2.0 percent in 2018 to their PFS covered professional services. 2016 was the last reporting period for PQRS. The final data submission timeframe for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March 2017. PQRS is being replaced by the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). The first MIPS performance period is January through December 2017.

CMS proposed and is finalizing a change to the current PQRS program policy that requires reporting of nine measures across three National Quality Strategy domains to only require reporting of six measures for the PQRS with no domain requirement. We are also finalizing similar changes to the clinical quality measure reporting requirements under the Medicare Electronic Health Record Incentive Program for eligible professionals who reported electronically through the PQRS portal.

We finalized these changes based on stakeholder feedback and to better align with the MIPS data submission requirements for the quality performance category. For MIPS, eligible clinicians need only report six quality measures for the quality performance category, except those reporting via the Web Interface, and there is no requirement to ensure that the measures span across three National Quality Strategy domains.

Patient Relationship Codes

In May 2017, CMS posted the operational list of patient relationship categories that are required under section 101(f) of MACRA. In this rule, we finalized certain Level II HCPCS modifiers to be used on claims to indicate these patient relationship categories. Further, we finalized a policy that the reporting of these HCPCS modifiers may be voluntarily by clinicians associated with these patient relationship categories beginning Jan. 1, 2018. We anticipate that there will be a learning curve with respect to the use of these modifiers, and we will work with clinicians to ensure their proper use.

Medicare Shared Savings Program

CMS is finalizing several modifications to the rules for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program. These modifications are designed to reduce burden and streamline program operations. The new policies include the following:

  • Revisions to the assignment methodology for ACOs that include FQHCs and RHCs by eliminating the requirement to enumerate each physician working in the FQHC or RHC on the ACO participant list;
  • Reduction of burden for ACOs submitting an initial Shared Savings Program application or the application for use of the skilled nursing facility (SNF) Three-Day Rule Waiver; and
  • The addition of three new chronic care management codes (CCM) and four behavioral health integration (BHI) codes to the definition of primary care services used in the ACO assignment methodology.

2018 Value Modifier

In order to better align incentives and provide a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program, we are finalizing the following changes to previously-finalized policies for the 2018 Value Modifier:

  • Reducing the automatic downward payment adjustment for not meeting the criteria to avoid the PQRS adjustment from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians;
  • Holding harmless all physician groups and solo practitioners who met the criteria to avoid the PQRS adjustment from downward payment adjustments for performance under quality-tiering for the last year of the program; and
  • Aligning the maximum upward adjustment amount to 2 times the adjustment factor for all physician groups and solo practitioners.
  • Given final policy changes for the Physician Quality Reporting System and the Value Modifier, we finalized that we will not report 2018 Value Modifier data in the Physician Compare downloadable database as this would be the first and only year such data would have been reported. However, to promote transparency we will continue to make available the Value Modifier public use and research identifiable files.

Posted in: CMS

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STUDY: Patients Prescribed Opioids in the ER Less Likely to Use Them Long Term

STUDY: Patients Prescribed Opioids in the ER Less Likely to Use Them Long Term

WASHINGTON – Compared to other medical settings, emergency patients who are prescribed opioids for the first time in the emergency department are less likely to become long-term users and more likely to be prescribed these powerful painkillers in accordance with The Centers for Disease Control and Prevention guidelines. A paper analyzing 5.2 million prescriptions for opioids is being published online today in Annals of Emergency Medicine (“Opioid Prescribing for Opioid-Naïve Patients in Emergency Department and Other Settings: Characteristics of Prescriptions and Association with Long-Term Use”).

“Our paper lays to rest the notion that emergency physicians are handing out opioids like candy,” said lead study author Molly Moore Jeffery, PhD., scientific director of the Mayo Clinic Division of Emergency Medicine Research in Rochester, Minn. “Close adherence to prescribing guidelines may help explain why the progression to long-term opioid use is so much lower in the ER. Most opioid prescriptions written in the emergency department are for a shorter duration, written for lower daily doses and less likely to be for long-acting formulations.”

In the emergency department, opioid prescriptions exceeding seven days were 84 to 91 percent (depending on insurance status) lower than in non-emergency settings. Prescriptions from the ER were 23 to 37 percent less likely to exceed 50 morphine milligram equivalents and 33 to 54 percent less likely to exceed 90-milligram equivalents (a high dose). Prescriptions from the ER were 86 to 92 percent less likely to be written for long-acting or extended-release formulations than those attributed to non-emergency settings.

Regardless of insurance status, patients receiving opioid prescriptions in the emergency department were less likely to progress to long-term opioid use. For patients seen in the ER, 1.1 percent with private insurance, 3.1 percent with Medicare (age 65 or older) and 6.2 percent with disabled Medicare progressed to long-term use. Put another way, patients with commercial insurance were 46 percent less likely to progress to long-term opioid use, Medicare patients age 65 and older were 56 percent less likely to progress to long-term opioid use and patients with disabled Medicare were 58 percent less likely to progress to long-term use if they received an opioid prescription in the emergency department.

“Over time, prescriptions written in the ER for high-dose opioids decreased between 2009 and 2011,” said Ms. Jeffery. “Less than 5 percent of opioid prescriptions from the ER exceeded seven days, which is much lower than the percentage in non-emergency settings. Further research should explore how we can replicate the success of opioid prescribing in emergency departments in other medical settings.”

Posted in: Opioid

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CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

The Centers for Medicare & Medicaid Services has redesigned its Medicare card to remove Social Security numbers and use a unique, randomly-assigned number in an effort to better protect users from identity theft and fraud.

CMS will begin mailing the new cards to people with Medicare benefits in April 2018 to meet the statutory deadline for replacing all existing Medicare cards by April 2019. People with Medicare will also be able to see the design of the new Medicare card in the 2018 Medicare & You Handbook. The handbooks are being mailed and will arrive throughout September.

“The goal of the initiative to remove Social Security numbers from Medicare cards is to help prevent fraud, combat identify theft, and safeguard taxpayer dollars,” said CMS Administrator Seema Verma. “We’re very excited to share the new design.”

CMS has assigned all people with Medicare benefits a new, unique Medicare number, which contains a combination of numbers and uppercase letters. People with Medicare will receive a new Medicare card in the mail, and will be instructed to safely and securely destroy their current Medicare card and keep their new Medicare number confidential. Issuance of the new number will not change benefits that people with Medicare receive.

Health care providers and people with Medicare will be able to use secure look-up tools that will allow quick access to the new Medicare numbers when needed. There will also be a 21-month transition period where doctors, health care providers, and suppliers will be able to use either their current SSN-based Medicare Number or their new, unique Medicare number, to ease the transition.

This initiative takes important steps towards protecting the identities of people with Medicare. CMS is also working with healthcare providers to answer their questions and ensure that they have the information they need to make a successful transition to the new Medicare number. For more information, please visit: www.cms.gov/newcard.

How can providers get ready for the changes?

  • Ask your billing and office staff if your system can accept the new 11-digit alphanumeric Medicare Beneficiary Identifier or
  • If your system cannot accept the new number, system changes should be made by April 2018
  • If providers use vendors to bill Medicare, ask them about their MBI practice management system changes and make sure they are ready for the change
  • Verify your patients’ addresses: If the address you have on file is different than the address you get in electronic eligibility transaction responses, ask your patients to contact Social Security and update their Medicare records. This may require coordination between your billing and office staff.

For more information go to https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html

Posted in: Medicare

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Fewer Physicians Could Be Audited under a New CMS Program

Fewer Physicians Could Be Audited under a New CMS Program

Fewer physicians will undergo audits under a new Medicare claims review process, according to a Centers for Medicare & Medicaid Services announcement.

CMS will roll out a new approach to claims review nationwide targeting fewer providers and requiring review of fewer claims. The new policy, to take effect later this year, makes it less likely doctors who have sound billing practices will face a Medicare audit.

Under the Targeted Probe and Educate (TPE) program, Medicare Administrative Contractors will focus “only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers,” according to the CMS announcement. Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.

Read the full CMS announcement here

Posted in: CMS

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Physicians Maintain High Standards

Physicians Maintain High Standards

By the time this article goes to print, a lot could change, so there’s no apparent use in guessing what will come of the next Repeal and Replace efforts or what’s happening at Main Justice. Nobody knows. The only certainties from Washington are that there will be change in the payment and insurance models, and that there will be more reports of arrests and prosecutions for alleged fraudulent schemes. Some practitioners express concern, but physician quality and innovation do not have to suffer because of these changes in law because physicians maintain high standards.

Neither Obamacare nor Ryancare nor Trumpcare nor the next iteration will actually change health care. Instead, they guide how health care services are paid. Payment certainly can influence quality, just as who pays for care can perhaps impact patient compliance. But quality care is neither guaranteed nor premised on any particular actual or proposed national structure. These laws do not provide anyone health care. You do, as physicians and nurses and hospitals. The Medical Association began with 30 physicians having a common goal of higher standards in an era with no insurance market at all, nor anesthesia like we know it today. It has always been appropriate for physician entrepreneurship to drive innovation and quality care with it, but there are limits.

The limits have always been there. Whether the changes of today will raise or lower the standard of care within any specialty, or chill entrepreneurship and innovation, is up to each provider. Understanding the legal bounds is often difficult for physicians, and sound legal advice is crucial to success because for every one announced prosecution or indictment there are untold stories of civil corporate misdeeds and aggressive strategies where specialized counsel could have maintained the high standard.

The Department of Justice under Attorney General Jeff Sessions announced in a July 13 news conference that 412 people were charged for participating in health care fraud amounting to more than $1.3 Billion. Pharmacists in Mississippi recently pleaded guilty to fraud charges, with one admitting” that he conspired with others to select compounded medication formulas based on profitability, rather than on effectiveness or patient need,” and that he dispensed medically unnecessary medications. The other pharmacist admitted to “soliciting physicians and other medical professionals to write prescriptions without seeing patients for medically unnecessary compounded medications dispensed by the pharmacy.”

In Virginia, “[a] medical doctor and entrepreneur was sentenced to [10 years] in prison . . . for defrauding his former company’s shareholders and for failing to account for and failing to pay employment taxes.” Ohio-based companies and their executives recently “agreed to pay approximately $19.5 million to resolve allegations pertaining to the submission of false claims for medically unnecessary rehabilitation therapy and hospice services to Medicare,” not that the therapy wasn’t performed or quality care – just that it was excessive and driven by profit over patients. Louisiana clinical psychologists were sentenced for a $25.2 million Medicare fraud scheme involving both unnecessary therapy and therapies never performed. A Florida physician pleaded guilty for his role in pain pill diversion and Medicare fraud scheme. An Alabama federal court enjoined a pharmacy from “distributing adulterated, misbranded and unapproved new drugs in violation of the federal Food, Drug, and Cosmetic Act.” A Tennessee physician settled false claims allegations of distributing and billing Medicare for drugs that had not been FDA-approved. This is all according to the Department of Justice in just the last month. Expect more, whether it’s from General Sessions or a successor.

These headlines should educate rather than frighten the physician entrepreneur with high standards. Each case can educate an intelligent professional that while billing guidelines and corporate laws may have positive or negative impacts on quality, usually indirectly, your standard of care owed to your patient and your business partners does not have to regress. These providers who fell into trouble with the Department of Justice may truly be outliers.

The Virginia “physician and entrepreneur” sentenced in July abused his investors’ trust, stole their money, and provided fraudulent financial statements. That’s an extreme case, perhaps, but consider the same case but where the physician and his investors lost trust in each other purely because of a lack of communication after a series of misunderstandings, and maybe some ego or fear. Perhaps the misunderstandings were fueled by further misunderstandings of medicine by the investors and misunderstandings of business by the physician. But I speculate on a hypothetical ripped from these DOJ headlines. Further, though, consider where the physician did not intend to steal anything but made blindly ignorant mistakes because he failed to ask for help or just maintained business as usual despite corporate changes. Consider the same story but where the financials were not intentionally fraudulent but in error or premised on aggressive billing practices, or an unwillingness to fully engage accountants for their services to pinch pennies. These seemingly more benign circumstances could be all too common, aggravated further by ego and competing visions or interests, and if unchecked and don’t make the DOJ alert then they could also lead to civil lawsuits.

A health care lawyer can answer questions and guide physicians to maintain high standards. The honest physician in need of compounded pharmaceuticals for patients could unwittingly become a co-conspirator like the Mississippi physician. The honest clinician is being driven to cut costs and increase revenue. The honest physician is brought into seemingly prudent arrangements that can turn sour. When a physician goes beyond medicine and into business, retaining legal counsel is critical to maintaining the same high business standards as physician strives for high standards in caring for patients. Specialists and trained sub-specialists are available.

Tom Wood is a partner in the Health Care Practice Group at Burr & Forman LLP and represents health care providers in regulatory and litigation matters. Buff & Forman LLP is a partner with the Medical Association.

Posted in: Legal Watch

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