medicare update wsmos march 11 2011 bernice hecker, md, mha, facc

MEDICARE UPDATE WSMOS

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)

– )NAS, LLC ProprietaryJanuar11 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


COST CONTROL

• MAC– FAR & Competitive Bidding– Consolidation– Staff efficiencies and reductions

• ACA– Prevention of disease– Delivery system– Payment reform– Fraud & abuse


Physician Quality ReportingSystem (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 (Non-

Covered Services LCD)


LCDs 2/3

• Retirements (cont.)– Stereotactic Body Radiation Therapy– Stereotactic Computer-assisted Volumetric

Navigation– Treatment of OSA– Wireless Capsule Colonography


LCD 3/3

• Potential LCDs– ESI (Epidural Steroids)– Vitamin D Assays

• Data Analyses


Dollars

COST CONTROL


• ACA– Prevention of disease– Delivery system– Payment reform– Fraud & abuse


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


2

1

2

1

4

3

5

7

9

10

15

8

6

11

14

13

12

New A/B MAC Jurisdictions

3

N

N

= Start-up

= Cycle One

= 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


COST CONTROL


• ACA: “Affordable Care Access”– Prevention of disease – Delivery system: EHR– Payment reform– Fraud & abuse


NAS, LLC Proprietary 22

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


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

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



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

COST CONTROL


• ACA: “Affordable Care Access”– Prevention of disease – Delivery system: Electronic magic– Payment reform– Fraud & abuse



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

2016 $2,000 $4,000 $4,000

Total $44,000 $44,000 $39,000 $24,000

For more information: http://www.cms.gov/EHRIncentivePrograms/

January 2011


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


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

http://www.cms.gov/ERXincentive

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



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

COST CONTROL


• ACA: “Affordable Care Access”– Prevention of disease – Delivery system– Payment reform– Fraud & abuse


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



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

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


RVUs: Impact on Oncologists

• E&M – variable• Drug Administration – 0-1% ↓• Capture office expense

– Know the Fee Schedule


Fee Schedule Lookup Tool

• Medicare Physician Fee Schedule (MPFS) tool

• CMS enhanced search http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

• MPFS Search Help– http://www.cms.gov/apps/physician-fee-sched

ule/help/Medicare-Physician-Fee-Schedule-Search-Help.pdf January 2011 NAS, LLC Proprietary 37

http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

http://www.cms.gov/apps/physician-fee-schedule/help/Medicare-Physician-Fee-Schedule-Search-Help.pdf




The investigator and You

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


http://www.cms.hhs.gov/ClinicalLabFeeSched

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


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


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

/


http://www.oig.hhs.gov/publications/workplan/2011/

http://www.oig.hhs.gov/publications/workplan/2011/


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.

http://www.healthdatainsights.com/index.aspx


CMS RAC Information

• CMS Web Site: www.cms.hhs.gov/RAC

• CMS RAC Email: [email protected]

http://www.cms.hhs.gov/RAC/

mailto:[email protected]


CERT Help

• Websites: – CMS:

• http://www.cms.hhs.gov/CERT/

– Noridian: • http://www.noridianmedicare.com

http://www.cms.hhs.gov/CERT/

http://www.noridianmedicare.com/


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

Thank You…..

What Questions Do You Have?

What Questions Do You Have?

medicare update wsmos march 11 2011 bernice hecker, md, mha, facc

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