Effective 1/1/2020, the AHS Fee Schedule will be adjusted to align with market and industry standards. Also, professional allowables for strep and flu tests will be updated.

Medicare is at the forefront of this change. Legislators and providers alike are struggling with how to move forward. Faced with an impending 20% reduction based on the SGR (sustainable growth rate) aspect of the current fee-for-service formula, Congress punted again.  A temporary fix for the SGR Medicare payment reduction was enacted on December 26, 2014.  The cut was replaced with a .5% increase.  However, this is only effective through March of 2014.  The intent was to give Congress a little more time to develop a permanent solution to the SGR problem.  Unfortunately, the passage of this legislation was also tied to the Ryan-Murray budget deal, which extended the sequestration cuts to Medicare through 2023.  The net effect is a little over a 1% reduction in payments.

In looking at  Medicare payments, most of the focus has been on the Conversion Factor associated with Medicare reimbursement.  That is the part of the payment formula that the SGR influences.  However, there are  Relative Value Units (RVU’s) associated with each CPT code that also affect payments.  These RVU’s are comprised of geographic cost factors, practice expenses, and the cost of malpractice insurance, each of which can fluctuate.  CMS reviews these annually, frequently making adjustments.  Depending on what CMS changes, the effect often varies among specialties.  For example, this year, the largest gains from RVU changes are for Chiropractors, Psychologists, and Clinical Social Workers.  Those specialties with the greatest loss are Diagnostic Testing Facilities, Pathology, Independent Labs, and Rheumatology.

While contending with reimbursement changes in Medicare’s fee-for-service model, providers are experiencing the prodding of CMS to begin looking at reimbursement from a different perspective, a result-driven or case management focus.  CMS wants providers to focus more on quality and less on just providing a service.  This can be illustrated by the move to reimburse providers for Care Coordination beginning in 2015.  Currently there are legislators indicating legislation may be introduced that provides a global payment for care of a chronic illness for a patient rather than paying for the individual services provided in the treatment of the illness.

CMS is also encouraging providers to utilize electronic health records and to measure performance based upon what it deems the standard of care should be for the treatment of a patient’s diagnosed problem.  This is reflected in the incentives and adjustments (i.e. penalties), associated with the implementation of electronic health records and PQRS (Physician Quality Reporting System) requirements.  The incentives are going away.  2014 is the last year a provider can qualify under Medicare criteria and receive incentive payments for implementation of an Electronic Health Record system.  This year will also be the last year for some PQRS incentive payments.  However, next year, 2015, will be the year providers will begin experiencing increased negative adjustments.

In addition to the 2% sequestration adjustment, an e-Rx penalty of 2% for not meeting requirements associated with electronically ordering prescriptions will be imposed.  Although this is the last year for the e-Rx penalty, 2015 will see penalties for failure to meet PQRS reporting requirements begin.  2015 will also see penalties for not meeting Meaningful Use requirements.  This will initially be a -1.5% adjustment for next year and increase to -2.0% for subsequent years.  Providers will also see the introduction of the VBM (value based modifier) in 2015 for clinics of 100 or more providers.  This penalty will apply to clinics of 10 or more in 2016 and to every provider in 2017.

It is important to understand that these adjustments are based on activity in prior periods.  For example, a PQRS adjustment applied to Medicare payments in 2015 is based on 2013 reporting activity.  So, to prevent future adjustments, steps must be taken now.  If a provider failed to meet requirements for PQRS participation, failed to implement an electronic health record system to meet meaningful use requirements, and did not meet VBM requirements, the provider could experience a 3.5% reduction in Medicare reimbursement.  Adding the impact of sequestration reductions, the total adjustments may be -5.5%.  Adjustments will increase over the next few years and may be as much as -11%.

Also on the horizon is the dreaded October 1, 2014 ICD-10 implementation date.  Most practices have been inundated with information on this topic to the point of becoming numb.  However, all indications are consistent that Medicare will not delay this implementation date.  Be prepared.  Providers should begin now examining the services they provide and develop a plan to learn how to code under the new guidelines.  Coding personnel in the practice need training.  The organizations providing the clinic’s EHR, Practice Management System, and Clearinghouse services should be monitored, and, if necessary, pushed to test and be compliant before the deadline.  And, the practice should build up cash reserves and/or establish a line of credit in anticipation that reimbursement delays are likely to arise.

Like recent years, 2014 portends to be an active one.  The SGR  issue is still unresolved and will need to be handled by March 31, 2014 to avoid payment hassles.  Practices will begin seeing patients enrolled in insurance plans through the Insurance Exchange or Marketplace, which will create its own set of problems.  The 2014 legislative session will see the introduction of “any willing provider” legislation.  The intent of this legislation is to prevent an insurance company from denying  a provider’s participation in a network if the provider meets the requirements for network participation.  Obviously, practice administrators must stay actively involved and informed to maintain a healthy revenue cycle.

Physician Quality Reporting System PQRS 2013

 Harold Ingram

CMS (The Centers for Medicare and Medicaid Services) created several quality initiatives intended to provide quality of care information for a variety of providers, in a number of different settings.  The rationale offered is that this information will be beneficial in empowering patients and will support new payment models that include quality of care measures in determining reimbursement.

The Tax Relief and Health Care Act of 2006 initiated this process by implementing the Physician Quality Reporting Initiative PQRI, which is now referred to as the Physician Quality Reporting System or PQRS.  As with some earlier health care related legislation, the passage of the Affordable Care Act (ACA) modified the PQRS program.  For the past several years, CMS has encouraged physicians to participate by offering incentives, the carrot.  However, beginning this year, 2013, CMS is bringing out the stick.  If physicians fail to participate in PQRS by reporting on services provided in 2013, a payment adjustment of -1.5% will be applied to all Medicare payments in 2015.  However, successful participation in the program will avoid the penalty. As an additional benefit, successful participation will also give the provider a .5% incentive payment or bonus for 2013.

If CMS determines that  a physician or group did not successfully participate through a qualified reporting option for 2013, Medicare payments for 2015 will be 98.5% of the Medicare allowable for the services provided.  As specified in the 2012 Medicare Fee Schedule, there are multiple ways to report PQRS activity.  These include (1) Claims-Based Reporting, (2) Registry-Based Reporting, (3) EHR-Based Reporting, and (4) Group Practice Reporting.  Information on the reporting methods are available on the CMS website.

At this point, the easiest way for a physician to report is through a qualified Registry.  A Registry is an organization that has met CMS requirements allowing it to report PQRS information on behalf of a provider.  If registry reporting is the selected reporting method, there are two options. One is through Individual Measures. The other is through measures groups.

Individual Measures registry reporting requires the physician to select at least 3 individual measures from a list of CMS approved measures.  For 2013, 138 individual measures were approved.  If this method is selected, the provider must report on at least 80% of the Medicare Part B fee for service patients seen in 2013.

Measures Groups registry reporting is probably going to be the easiest way to report.  It provides for two reporting periods, January 1, 2013 through December 31, 2013 or July 1, 2013 through December 31, 2013.  It will require the selection of at least one measures group.  And, the physician will have to report on at least 20 patients.  A minimum of 11 of these patients will have to be Medicare Part B patients.

To obtain additional information on PQRS, the reporting requirements, and the measures that may be selected, go to the CMS website and search for PQRS measures.  Twenty-two (22) measures groups were approved for 2013.  One frequently selected is the Diabetes Measures Group.

To get an idea of what is required to report on a measures group, MDinteractive has a brief tutorial for its registry at www.mdinteractive.com that demonstrates the information needed for reporting purposes.  The cost for using a registry is generally between $200 and $300.

There are a number of organizations authorized to submit information on the behalf of physicians.  These Registries will provide guidance and assistance in collecting, qualifying, and reporting PQRS data.  Many specialty groups or societies offer this service to their members.  Some Registry websites that you may wish to visit for further reporting information are:

-  www.mdinteractive.com

-  www.pqrspro.com

-  www.wellcentive.com

-  www.pqrssolutions.com

This type of reporting is just a pre-cursor to the requirements physicians will face for future reimbursement.  PQRS reporting is currently a Medicare requirement that provides a limited assessment of the quality of care provided.  However, as payment models change, there will be more emphasis on measuring quality, like PQRS, as well as measuring the expense associated with treating patients.  Expect these new models to apply to all insurance carriers, Medicare, Medicaid and commercial.

August 15, 2013

Harold Ingram

Enrollment will begin October 1, 2013, in the federally administered Insurance Exchange for Mississippi.  Currently there are still a lot of questions to be answered.  How much will insurance cost through the Exchange?  Will there be only two insurers to participate?  Will patients have to give up current insurance plans because of the Affordable Care Act (ACA) and participate in the Exchange?  Is a provider required to participate?  Who will be the “Navigators” to help enroll people in the Exchange?

One of the objectives of the Exchange is to provide individuals and families without insurance coverage the opportunity to obtain coverage at a competitive price.  Under the program, individuals would be placed in a pool large enough to share risk across a broader spectrum of patients and thereby command lower premiums. The key to this philosophy is the requirement for younger, healthier people to enroll.  However, reduced premiums may not actually be realized.  Other aspects of the ACA affecting coverage requirements may influence a rise in insurance costs, especially for those people with high deductibles and limited coverage plans.

The Exchange offers insurers the opportunity to offer four different levels of coverage at varying levels of expense to people seeking coverage through the Exchange.  Also, there will be subsidies to patients based upon income level.  The individual expense for the levels of coverage have not been set at this time.

Currently, two insurers, Humana and Magnolia Health Plans (Centene), have agreed to participate.  However, the only counties in which both will offer coverage are Desoto, Hinds, Madison, and Rankin.  Included in Appendix A is a list of the counties covered by each carrier.

The Humana plan will be administered through First Choice.  Providers currently enrolled with First Choice received letters earlier indicating that First Choice would have a network company that would be participating in the Exchange.  At that time, the carrier was not identified.  The letter indicated that unless a provider specifically opted  out, it would be assumed that the provider would offer services to patients covered by the Exchange plan at a 5% reduction of the First Choice fee schedule.  For providers choosing to  participate but not currently enrolled in First Choice, they should initiate enrollment activity soon.  Participation approval can take several months.

Although Magnolia Health Plans (Centene) participation activity can be addressed directly with the company, Mississippi Physicians Care Network (MPCN) will also be facilitating participation activity and should probably be contacted initially by interested providers.  MPCN issued letters in the latter part of May to their network providers who were participating in MScan program with Magnolia Health Plans.  This letter was accompanied by an addendum which the provider was required to sign if he chose to participate.  As with First Choice, providers who have not signed the addendum and wish to participate with Magnolia Health Plans need to act quickly, contacting MPCN for enrollment.

As information continues to trickle in, more is being understood about the impact of the ACA, including the Exchange.  One exchange issue that is causing concern focuses on patients who stop paying premiums to an exchange participating insurer.  Under current guidelines, the insurer must continue to offer coverage to the patient for up to 90 days after the patient becomes delinquent in premium payments. However, the insurer is only required to provide benefit payments of the first 30 days. It is the insurer’s responsibility to notify participating providers that a patient is delinquent and has the potential to have his coverage terminated. The specifics on how the insurer will notify providers is unclear at this time.

If services are provided to an exchange patient after being delinquent for more than 30 days and the patient is terminated, those provider claims could be denied by the insurer.  Under those circumstances the provider would have to seek payment directly from the patient.  Administratively, processes would need to be implemented to address this issue.  For example, it may be necessary to verify the status of each exchange patient each time they visit the clinic, assuming the insurer had a means of identifying delinquent patients.  Whereas it is good office policy verify insurance coverage for each patient every visit, it may not be practically feasible to do so.  The degree of risk associated with such circumstances will probably not be known until the process to notify providers of delinquent patients is presented and evaluated.

As an unintended consequence of the ACA, it may have removed an incentive to encourage patients to  keep premium payments current. In circumstances where pre-existing conditions exist, prior to the ACA, it might prove difficult for a patient to obtain other insurance coverage because of pre-existing condition exclusions. That would encourage the patient to keep the insurance from lapsing.  Some have speculated that savvy patients may even try to game the system by making 9 premium payments but getting a full year’s benefit because of the 90-day termination specification.

The State will soon see a major push to enroll people in the Exchange through groups known as “Navigators”.  A navigator is someone who can assist people in the enrollment process, helping them understand the various options and associated expenses.  Navigators will also reach out to communities informing them of the Exchange (also referred to as the Marketplace).  The Navigator Organizations receiving grants to provide this service for Mississippi are:

Oak Hill Missionary Baptist Church Ministries (anticipated grant amount $317,742)

University of Mississippi Medical Center                     (anticipated grant amount $831,986)

Oak Hill will service the lower Delta area training clergy to be health ambassadors reaching out to uninsured residents to assist in the enrollment process.  UMC will cover the entire State educating and assisting in enrollment in Medicaid, CHIP, and the Exchange.

Providers need to decide as soon as possible whether or not they want to participate. In some areas the Exchange may offer providers a significant opportunity to acquire additional insured patients if prices are reasonable.  The cost to patients for the various levels has not been identified and will be impacted by patients’ income.  As mentioned earlier, First Choice will assume a provider will participate unless the provider replied to a previous letter from First Choice indicating he wished to opt out.  However, First Choice may allow providers to opt out now if the provider notifies First Choice prior to October.

Unlike First Choice, providers wishing to participate in the Magnolia Health Plans program will need to initiate enrollment activity.  It is not automatic even if the providers currently participate in the MScan Magnolia Health Plans program.  MPCN should be contacted as a first step in the participation process.

As with the Insurance Exchange or Marketplace, it is important that providers and clinics maintain vigilance as the full impact of the ACA unfolds.  There may be a number of unanticipated and unintended consequences as full enactment of the ACA is realized.

Appendix A

Counties Served by Exchange Providers

 Humana

Adams                         Grenada                                  Leflore                         Smith

          Alcorn                          Hancock                                  Lincoln                         Sunflower

             Amite                           Hinds*                                     Madison*                     Tallahatchie

          Attala                           Holmes                                    Marion                         Tishomingo

   Bolivar                         Humphreys                          Montgomery                Walthall

           Carroll                         Jefferson                                 Pearl River                  Washington

Choctaw                      Jefferson Davis                       Pike                             Wayne

    Covington                    Jones                                      Rankin*                       Wilkinson

Desoto*                       Lawrence                                Scott                            Winston

      Franklin                       Leake                                      Sharkey                       Yalobusha

Magnolia Health Plans

         Benton                         Harrison                                  Madison*                     Quitman

     Calhoun                       Hinds*                                     Marshall                      Rankin*

         Chickasaw                   Issaquena                               Monroe                        Simpson

     Claiborne                     Itawamba                                Neshoba                      Stone

Clarke                          Jackson                                   Newton                        Tate

       Clay                             Jasper                                     Noxubee                      Tippah

          Coahoma                    Kemper                                   Oktibbeha                    Tunica

         Copiah                         Lafayette                                 Panola                         Union

           Desoto*                       Lamar                                      Perry                           Warren

              Forrest                         Lauderdale                           Pontotoc                      Webster

         George                        Lee                                          Prentiss                        Yazoo

              Greene                                   Lowndes

 * Counties in which both companies participate

The reason this may be of interest to physicians is because it will be made public.  Once CMS publishes it, patients, whistleblowers, media outlets, and others will be able to access it.  If physicians wish to continue to receive lunches, travel, honoraria, or other benefits from device and drug companies, they should monitor what the manufacturers will report concerning the value of the items or services received.  Given a scenario where a device manufacturer has a problem with an item it manufactures, the negative publicity from it might spill over to a physician who has received benefits from the company.  By searching the CMS database, media outlets might identify and publicize the names of physicians receiving benefits from the company that manufactured the defective device. This could present a sticky public relations situation for a physician receiving significant payments from that manufacturer.

Clinics and physicians may want to evaluate current policies as they relate to items provided by companies covered under the Sunshine Law.  Although it will not be necessary to curtail benefits such as paid lunches, some clinics may choose to do so rather than increase the administrative burden required to monitor the activity.

It appears that the intent of this provision of the ACA is to highlight compensation in any form received from device manufacturers and drug companies by physicians in an attempt to limit the impact of such compensation on what the physician recommends for the treatment of the patient.  With the availability of this information, correlations between a physician’s recommendations and compensation received might be developed.   From the correlations, inferences could be made concerning the physician’s choice of products and factors influencing the physician’s decision.

If a physician receives something of value from a manufacturer but does not use or promote anything from that manufacturer that CMS considers a “covered item”, the manufacturer may still be required to report the valued amount to CMS.  If the manufacturer has any “covered item” that it produces, it has the responsibility of reporting all payments and transfers of value to CMS for all physicians where the value of payments or services is $100 or more in a year.  For example, if a DME representative takes a physician to dinner but the physician utilizes nothing that the DME company has that is covered by Medicare, it would seem reasonable that nothing would have to be reported.  However, that may not be the case.  If the DME company produces a brace that is utilized by physicians in another specialty, the company would be required to report the value of the meal to CMS.  In essence, if a manufacturer has even one item that is covered by Medicare, Medicaid, and/or CHIPS, “perks” for all physicians must be reported.

Reporting is on an individual physician basis and not by group.  Therefore, reported items must be broken down in such a way that the value can be allocated at an individual level.  For example, a drug representative may bring lunch to an office for five staff personnel and a single physician.  If the meal costs $120, the amount allocated to the physician for that meal would be $20 (i.e. $120 divided by 6).  If a meal is provided for staff only, the value of the meal is not reportable to CMS for any physician in the clinic.

Basically, anything that is provided by a manufacturer that can be associated with a specific physician will probably be reported.  This would include honoraria, travel, meals, meeting fees, tickets to ballgames, gifts, etc.  As could be expected, there are exceptions.  For example, a manufacturer contributing money to a society sponsored conference that did not provide payment for any specific physician would not be required to report this for any physician.  Lunches provided for all physicians attending a seminar would likely not be reportable.  However, if a manufacturer took the physician out for dinner at a conference, that would be reportable.

In addition to manufacturers, Group Purchasing Organizations, GPO’s, also have reporting requirements.  However, these are limited to ownership relationships.  The GPO is required to report any ownership interest by a physician or a member of the physician’s family and distributions they receive from the GPO.  Discounts received through a GPO are not reportable.

Manufacturers are required to provide their reports to CMS by March 31st.  CMS will publish this information by September 30th.  There will be a 45 day period in which a physician may contest the amount reported by the manufacturer allowing for corrections to be made.  Physicians who have signed up on the CMS website associated with Open Payments will be notified that a report has been made.  However, the physician must initiate the process by enrolling.  As it currently stands, the physician is responsible for enrollment and should not delegate it to a staff member.

Clinics should develop internal controls to monitor reportable items.  For in-office activities such as lunches, the clinic should identify the physicians that eat and identify how the organization providing the meal will be allocating the value to the physicians.  Also, for physicians that attend out of town meetings, a mechanism for capturing any items provided by manufacturer representatives should be developed.

It would be helpful to develop relationships with the reporting organizations whereby the organization would provide a physician access to the information they will be reporting before sending it to CMS.  This would allow corrections before CMS has access to the information.  Although it may be corrected once it is sent to CMS, it is unclear how soon corrections could or would be made.

For additional information, CMS has an Open Payments Fact Sheet that is helpful.  That information is available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/Downloads/Physician-fact-sheet.pdf

]]> http://performax.biz/?feed=rss2&p=207 0 http://performax.biz/?p=188 http://performax.biz/?p=188#comments Wed, 15 May 2013 03:38:52 +0000 admin http://performax.biz/wordpress/?p=188  

Social media in the medical industry is becoming a part of everyday life for many physicians.  Although the health industry has been reluctant to adapt, in the past few years it has started to expand.  More than 90% of doctors use at least one social network, including 65% who use those sites for professional purposes.  Social media is a way of connecting and sharing information with your patients for little to no expense.  It is a wave that will eventually engulf every clinic whether it is embraced or ignored.

Social media has a number of benefits. The top use of social media for physicians includes sharing experiences and advice with their peers and developing referral networks. It can also be a great informative tool for patients.  66% of Americans search the web for illnesses or related diseases.  If patients are going to the internet for medical information, why not try to persuade them to come to your site for that information.  This can easily be accomplished by writing blogs and answering generic questions asked by your patients. The key element is to post pertinent information specific to the physician’s patient base or to a specific type of patient the physician is trying to recruit.

It is also a good way to send out information to a large number of patients in a matter of seconds.  Twitter is great for this type of communication.  Perhaps there is a personal emergency and the physician will be out for a few days, or a medical fair is scheduled and the clinic would like to get information out to its patients.  With the proper use of twitter, patients can instantly see messages sent by the physician from anywhere.  Twitter has an added benefit since it is more acceptable in the workplace than other media types.  Because of the impact of productivity, many businesses and clinics are starting to ban Facebook and other similar media outlets.

Social media can be used both for informational purposes and a place where the patients can socialize.  OBGYNs, embracing social media, often have patients post pictures of their children.  This frequently leads to positive comments which in turn are associated with the practice, increasing its marketability.  This type of marketing encourages word of mouth which is the most powerful type of marketing available.  The uses for social media are limitless.

However many physicians jump in and create a Facebook or a Myspace account and have little success, or end up creating more problems than they solve by introducing social media in their practice.  One of the biggest challenges is that most doctors are willing to spend money, but not time on social media. This can work if implemented properly.  Most social media is best implemented by having an authentic voice associated with it.  Paying someone to be an authentic voice is quite a challenge. Therefore, for a clinical practice to do well with social media, the physician and staff must carve out time to engage with it.

When implementing a social media strategy, a few important rules to ensure positive feedback and protection are as follows:

• Develop a strategy and decide what information you want to portray, how often to update it, and what you would like to get out of social media marketing.
• Determine how much time you and your staff are willing to be involved and update your site frequent enough to keep patients interested.  However, do not post too often because this can have an adverse affect and cause people to lose interest.
• Setup protocols to ensure negative activity does not occur.  In most of the media outlets, you have the capability to delete any negative remarks, or approve any remarks before they are made public.  This should be a daily maintenance and to ensure your site remains professional and positive.
• Be wary of HIPPA violations and do not answer specific questions, only general ones.  Do not post any information that is specific to a patient or that can identify who that patient is in any way.   This is a fear shared by many physicians.
• Before posting anything, have an approval process that will require at least two people to proof read the post before submitting it.  This is a key process to ensure no HIPPA violations occur and to keep the postings professional with no misspelled words or grammar.

Social media is not for every physician, but with a proper strategy, a well thought out plan, time and dedication; it can impact a medical clinic in a positive way through multiple avenues. Be cautious when deciding to use social media and determine if you and your staff are willing to spend the time needed.  Know what you expect to get out of it and follow the guidelines set forth above and you will have a much better chance of benefiting positively through social media.