Download Making Medicare Work for You - Washington State Medical

MEDICARE UPDATE
WSMOS
March 11 2011
Bernice Hecker, MD, MHA, FACC
Overview
• CMS & ACA: Increase access to valuable
services
• Identify Value
– Pay for Value Programs
– LCDs (Comparative Effectiveness)
• Control Costs
– MAC
– Prevention of Disease
– PFS Changes
– Anti Fraud & abuse (MD Signatures, OIG)
Januar11
NAS, LLC Proprietary
2
CMS: Cares about Medicare
Service(s)
•
•
•
•
CMS attitudes = Congressional beliefs
Sky high costs and plummeting access
MDs as key to access & cost
Help or Hindrance
– CMS comments
– Assist local Contractors
– Medical society advocacy
– AMA/other
Winter 2011
NAS, LLC Proprietary
3
INCREASE ACCESS: ACA
• Shift dollars by shifting incentives
– Pay for Value
– LCDs & other comparative effectiveness
efforts
– Specialists vs. primary care
• Payment reform
– PFS changes
– ACO
– Medical Home
Winter 2011
NAS, LLC Proprietary
5
COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA
– Prevention of disease
– Delivery system
– Payment reform
– Fraud & abuse
Winter 2011
NAS, LLC Proprietary
6
VALUE
Physician Quality Reporting
System (PQRS)
• Formerly referred as PQRI (Incentive)
• 1% payment bonus continues for 2011
• 194 total measures
– 5 new measures – claims/registry reporting
– 11 new registry – only measures
– 4 new measures - Electronic Health Records (EHR)
based reporting only
– 5 deleted measures
• 20 EHR measures
– 14 measures groups (e.g. Asthma = new measure)
January 2011
NAS, LLC Proprietary
8
LCDs 1/3
• Draft
– B-Natriuretic Peptide (BNP), comment 4/22
– Vertebral Augmentation Procedures
• Retirements
– CT Colonography
– MD CTA (Multidetector CT Angiography)
– Plastic Surgery
– Artificial Disc (Non-Covered Services)
– Endoscopic Treatment of GERD (NonCovered Services LCD)
Winter 2011
NAS, LLC Proprietary
10
LCDs 2/3
• Retirements (cont.)
– Stereotactic Body Radiation Therapy
– Stereotactic Computer-assisted Volumetric
Navigation
– Treatment of OSA
– Wireless Capsule Colonography
Winter 2011
NAS, LLC Proprietary
11
LCD 3/3
• Potential LCDs
– ESI (Epidural Steroids)
– Vitamin D Assays
• Data Analyses
Winter 2011
NAS, LLC Proprietary
12
Dollars
COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA
– Prevention of disease
– Delivery system
– Payment reform
– Fraud & abuse
Winter 2011
NAS, LLC Proprietary
14
MAC: Phase 2
• 15 A/B MAC Jurisdictions
• 9/15 implemented
• 6/15 in protest or corrective actions
– 2, 6, 8, 11,15
• J2 (WA) award – Summer 2011
• Re-Bids began last summer - J3
• Consolidation – 15 to 10
– Jur2 + Jur3 = Jur F
Winter 2011
NAS, LLC Proprietary
15
New A/B MAC Jurisdictions
14
2
3
13
6
12
8
1
5
15
11
4
10
3 = Start-up
7
N = Cycle One
2
9
1
N = Cycle Two
Five Consolidated A/B MAC
Contracts
• JURISDICTION F- A/B MAC Jurisdictions 2 and 3 (Alaska,
Washington, Oregon, Idaho, North Dakota, South Dakota,
Montana, Wyoming, Utah, and Arizona)
• Jurisdiction H- A/B MAC Jurisdictions 4 and 7 (Louisiana,
Arkansas, Mississippi, Texas, Oklahoma, Colorado, and New
Mexico)
• Jurisdiction G- A/B MAC Jurisdictions 5 and 6 (Minnesota,
Wisconsin, Illinois, Kansas, Nebraska, Iowa, and Missouri)
• Jurisdiction I- A/B MAC Jurisdictions 8 and 15 (Kentucky, Ohio,
Michigan, and Indiana)
• Jurisdiction K- A/B MAC Jurisdictions 13 and 14 (New York,
Connecticut, Massachusetts, Rhode Island, Vermont, Maine, and
New Hampshire)
A/B Contracts that are not
consolidated
• Jurisdiction E- A/B MAC Jurisdiction 1 (California, Hawaii, Nevada,
Pacific Islands)
• Jurisdiction N- A/B MAC Jurisdiction 9 (Florida, Puerto Rico, US
Virgin Islands)
• Jurisdiction J- A/B MAC Jurisdiction 10 (Alabama, Georgia,
Tennessee)
• Jurisdiction M- A/B MAC Jurisdiction 11 (North Carolina, South
Carolina, Virginia, West Virginia)
• Jurisdiction L- A/B MAC Jurisdiction 12 (Delaware, Maryland,
Pennsylvania, New Jersey, Washington DC)
Impact: Medical Director
• Competition – sharing
• Ongoing reassessment of values
– U.S., CMS, NAS, personal
• More work with less staff
• Community support
– Risk
– Assistance
– Idealism vs. Realism
Winter 2011
NAS, LLC Proprietary
20
COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA: “Affordable Care Access”
– Prevention of disease
– Delivery system: EHR
– Payment reform
– Fraud & abuse
Winter 2011
NAS, LLC Proprietary
21
Preventive Services
• Effective January 1, 2011
• Part B deductible and coinsurance will be
waived for most preventive services
– Provision waives both for preventive services with
a grade of A or B by U.S. Preventive Service Task
Force (USPSTF)
– Deductible will be waived for tests that begin as
screening and change to diagnostic or
therapeutic services
• I.e. colorectal cancer screening
• CR7012
January 2011
NAS, LLC Proprietary
22
Screening Recommendations
• Several preventive services covered by Medicare do
not have a USPSTF recommendation grade of A or B
– Barium enemas provided as colorectal cancer screening
tests, coinsurance applies
• Screening barium enema, deductible is waived under another
section of statute
• Deductible and coinsurance apply:
– Digital rectal examinations provided as prostate screening
tests
– DSMT services
– Glaucoma screening
– Screening electrocardiograms performed for IPPE
• Deductible and coinsurance continues to apply to
other services
January 2011
NAS, LLC Proprietary
23
Annual Wellness Visit
• CR 7079 may include the following:
– Establish/update medical/family history
– List providers/suppliers/medications
– Record measurements of height, weight,
body mass index, blood pressure & other
routine measurements
– Detect any cognitive impairment
– Establish/update a screening schedule for
patient to follow over next 5-10 years
– Furnish personalized health advice and
appropriate referrals to health education
January 2011
NAS, LLC Proprietary
24
New Covered Preventive Service
– Annual Wellness Visit
2
• G0438 – Annual wellness visit, including
personalized prevention plan services, first
visit
– Paid at level 4 office visit for new patient (similar
to IPPE)
• G0439 – Annual wellness visit, including
personalized prevention plan services,
subsequent visit
– Paid at level 4 office visit for established patient
January 2011
NAS, LLC Proprietary
25
COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA: “Affordable Care Access”
– Prevention of disease
– Delivery system: Electronic magic
– Payment reform
– Fraud & abuse
Winter 2011
NAS, LLC Proprietary
26
Electronic Health Records (EHR)
Calendar
Year
Maximum Incentive Payments Based on the First CY
an EP Participates in the Program
2011
2012
2013
2014
2011
$18,000
2012
$12,000
$18,000
2013
$8,000
$12,000
$15,000
2014
$4,000
$8,000
$12,000
$12,000
2015
$2,000
$4,000
$8,000
$8,000
$2,000
$4,000
$4,000
$44,000
$39,000
$24,000
2016
Total
$44,000
For more information: http://www.cms.gov/EHRIncentivePrograms/
January 2011
NAS, LLC Proprietary
27
EHR Payment Adjustments
• 2015 payment adjustments begin
– EPs do not successfully demonstrate “meaningful
use” of certified EHR technology
• Payment adjustments will be:
–
–
–
–
2015 – 99% of MPFS allowed amount (80%)
2016 – 98%
2017 – 97%
By 2018 and subsequent years, if less than 75%
of EP’s are meaningful users, payment will
change by 1% each year until adjustment
reaches 95%
January 2011
NAS, LLC Proprietary
28
E-Prescribe (eRx)
• Electronic transmission of prescriptions
– Takes place between a prescriber, dispenser,
pharmacy benefit manager or health plan
– Can take place through an intermediary – eRx
network
– Began in 2009 – came from MIPPA legislation
• Medicare Improvements for Patients and Providers Act of
2008
• Promotes adoption/use of eRx systems
– eRx provides a combination of incentives and
payments adjustments for providers who are not
successful electronic prescribers
– Details: http://www.cms.gov/ERXincentive
January 2011
NAS, LLC Proprietary
29
Electronic Prescribing
(E-Prescribing or eRx)
• 1% incentive bonus continues for eligible
electronic prescriptions
• Individual “eligible providers” must still
meet qualified system standards
• Group option broadened (less than 200)
• 2012 starts imposed payment adjustment
January 2011
NAS, LLC Proprietary
30
eRx
2
Medicare Incentives for eRx
2011
1% Incentive payment
2012
1%
2013
0.5%
eRx Payment Adjustments may occur for not being a successful
electronic prescriber
2012
Receive 99% of EP or group practice Part B covered services
2013
Receive 98.5%
2014
Receive 98%
It is possible to receive an eRx incentive payment for 2011 AND an
eRx payment adjustment for 2012
January 2011
NAS, LLC Proprietary
31
COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA: “Affordable Care Access”
– Prevention of disease
– Delivery system
– Payment reform
– Fraud & abuse
Winter 2011
NAS, LLC Proprietary
32
Reform: Shift Incentives
• Primary Care & Gen Surg incentives
– Increase access, prevent or early treatment
– Medical Home
• PFS (Examples)
– Bundling of services (card, rad onc)
– Imaging Families and TC ↓
– RVU updates
• MEI Re-basing
• ACOs
Winter 2011
NAS, LLC Proprietary
33
Multiple Procedure Payment Reduction on
TC of Certain Diagnostic Imaging
Procedures
• Effective January 1, 2011
• CMS is consolidating existing 11 advanced
imaging families into a single family
• Applies:
– When two or more services on list are furnished to
same patient in a single session
– Only to Technical Component (TC) portion of global
services
– Full TC payment for procedure with highest priced TC
– 50% for TC of each additional procedure on same
patient in same session
• CR6993
January 2011
NAS, LLC Proprietary
34
RVUs
• RVU = Work, PE, PLI x conversion factor
• PPIS (Phys Pract Info Survey) – year 2/4
– Practice Expenses
• MEI (Medicare Economic Index):
– ↓ Work 52.466 to 48.266)
– ↑PE (43.669 to 47.439)
– ↑PLI (3.865 to 4.295)
EX: ↑Rad Onc
Winter 2011
NAS, LLC Proprietary
35
RVUs: Impact on Oncologists
• E&M – variable
• Drug Administration – 0-1% ↓
• Capture office expense
– Know the Fee Schedule
Winter 2011
NAS, LLC Proprietary
36
Fee Schedule Lookup Tool
• Medicare Physician Fee Schedule
(MPFS) tool
• CMS enhanced search
http://www.cms.gov/apps/physician-feeschedule/overview.aspx
• MPFS Search Help
– http://www.cms.gov/apps/physician-feeschedule/help/Medicare-Physician-FeeSchedule-Search-Help.pdf
January 2011
NAS, LLC Proprietary
37
The investigator and You
NAS, LLC Proprietary
39
Signature on Requisitions for
Clinical Diagnostic Lab Tests
• November 29, 2010 Federal Register final rule
proposed policy to require a physician’s or Non
Physician Practitioner’s (NPP’s) signature on
requisitions for clinical diagnostic laboratory tests
paid under clinical laboratory fee schedule
• First quarter of 2011, CMS will develop education
and outreach materials to build awareness and
understanding in physician community
– Once first quarter educational campaign is fully
underway, CMS will expect requisitions to be signed
– http://www.cms.hhs.gov/ClinicalLabFeeSched
• JSM/TDL 11097 dated December 20, 2010
January 2011
NAS, LLC Proprietary
40
2011 OIG FOCUS
• Place of Service (POS) errors
– Services performed in Ambulatory Surgery Centers
(ASCs) and hospital outpatient settings
• Coding & payments for Evaluation and Management
(E/M) services
– E&M services during global surgery periods
• Portable x-ray suppliers billing
• Outpatient physical therapy services provided by
independent therapists
• Questionable billing for outpatient therapy services
• Excessive payments – unusually high claim amounts
January 2011
NAS, LLC Proprietary
41
2011 OIG FOCUS
2
• Appropriateness of payments for
polysomnography
• Payments for sleep testing
• Lab test unbundling by clinical labs
• Billings with modifier GY
• Medicare Secondary Payments (MSP)/other
insurance coverage
• Brachytherapy reimursement
• Observation services during outpatient visits
• Part B payments for home health beneficiaries
January 2011
NAS, LLC Proprietary
42
2011 OIG FOCUS
3
• Services performed by Clinical Social
Workers (CSWs)
• Excessive payments for diagnostic tests
• Laboratory test unbundling by clinical
laboratories
• Geographic areas with high density of IDTF’s
• Error-prone providers: Medicare Part A & B
• CERT for FY 2010 error rate oversight
• http://www.oig.hhs.gov/publications/workplan/
2011/
January 2011
NAS, LLC Proprietary
43
Region D Contractor
• HealthDataInsights, Inc.
– 7501 Trinity Peak Street, Suite 120
Las Vegas, NV 89128-6896
888-700-3282
http://www.healthdatainsights.com/index.aspx
• Subcontractor: PRG Schultz, Inc.
NAS, LLC Proprietary
44
CMS RAC Information
• CMS Web Site: www.cms.hhs.gov/RAC
• CMS RAC Email: [email protected]
NAS, LLC Proprietary
45
CERT Help
• Websites:
– CMS:
• http://www.cms.hhs.gov/CERT/
– Noridian:
• http://www.noridianmedicare.com
NAS, LLC Proprietary
47
Appeal, Appeal, Appeal!
• If you disagree with the outcome of the
CERT review, appeal the claim!
• Appeals will be processed by NAS
• No amount is too small, and the outcome
may dramatically reduce your facility error
rate
NAS, LLC Proprietary
48
Thank You…..
What Questions
Do You Have?