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Tuesday, July 8, 2014

CMS looks to tweak Open Payments reporting for CME events

The Centers for Medicare & Medicaid Services (CMS) Open Payment initiative hasn't truly gone into effect yet and its framers already want to change it.

The Open Payment program, which tracks and discloses financial relationships between physicians and drug and device manufacturers, will begin releasing that information by the end of September. Physicians will be able later this month to review the information reported about them and report any errors.

But in the 2015 Physician Fee Schedule proposed rule announced on July 3, CMS proposed some changes to the program based on feedback from stakeholders since the original rules were introduced last year.

Chief among those changes is a proposal requiring that applicable manufacturers disclose any payments or other transfers of value made to speakers at continuing education programs.

These types of payments had been excluded under the current rules, assuming they met three criteria:

• The speaker is appearing at a program accredited or certified by the ACCME, AAFP, ADA, AMA, or AOA,
• The manufacturer does not pay the speaker directly,
• The manufacturer does not choose the speaker or provide the third-party organizer with a list of preferred speakers.

CMS said commenters have argued that limiting the exemption to speakers at events tied to just those five organizations made the reporting requirements inconsistent and appeared to give continuing education events held by those five organizations CMS's "endorsement or support."

The agency said this was an "unintended consequence" and proposed removing the exemption language in its entirety.

Open Payments already has a general exemption for indirect payments or transfers of value where the manufacturer does not know the identity of the recipient, so payments and transfers of value to speakers would remain exempt under that rule, provided the manufacturer doesn't directly pay the speaker or provide the third-party organizers with a list of preferred speakers.

Monday, June 30, 2014

Physician recruiter sees continued plunge in private practive

One of the largest physician recruiters in the country says the market for private practice, at least among its clients, is drying up quickly.

According to an annual review by physician search firm Merritt Hawkins, less than one in 10 of the company's 3,158 search assignments between April 1, 2013, and March 31, 2014, were for independent practice settings, such as partnerships, solo offices, or concierge/direct pay practices.

The vast majority of assignments were for employed positions, with 64 percent going to hospitals and the remainder serving large groups, community health centers, or academic facilities.

By comparison, independent practice situations made up more than 45 percent of Merritt Hawkins' search assignments in 2004.

Researchers said the mounting economic and regulatory pressures of the Affordable Care Act and other changes in the health care landscape continue to fuel the shift of physicians, who typically view employed positions as more financially stable and free of the burdens of running their own practices.

Overall, there were 714 searches for family medicine, making it the most requested recruiting assignment for the company for the eighth year in a row. The next most-popular search was for internal medicine, with 235 assignments.

The average base salary for family medicine assignments during the study period was $199,000, the highest average in the last five years. That average salary is a little higher than the $190,907 found in a recent study of AAFP members.

"Concierge" and other practice models where patients directly pay the physician a retainer or other regular fee for increased access has also grown. Merritt Hawkins said it completed 32 searches during the past year for these positions – only 1 percent of total searches but an increase from 10 searches two years ago. 

The ongoing shift of medical reimbursement from models based on volume to those based on quality and value has been difficult for health care organizations, and it shows in the incentives used to attract physicians. Researchers said only 24 percent of the company's recruiting assignments included production bonuses based at least partly on quality and value, a decrease from 39 percent of assignments during the previous year.

Production bonuses based on Relative Value Units (i.e., the work units performed by a physician) are still the most common. Fifty-nine percent of assignments included that type of bonus versus 57 percent last year.

Tuesday, June 24, 2014

Medicare to expand its use of prior authorization

The Centers for Medicare & Medicaid Services (CMS) is looking to expand its requirements that it provide prior authorization before Medicare beneficiaries can receive certain medical devices or supplies.

In a May release, CMS said it plans to more than double the number of states where it has prior approval power over power mobility devices, launch new prior authorization trials for two types of non-emergency services, and get public comment on establishing prior authorization rules for a number of other devices and supplies it says are frequently prescribed to patients who don't need them.

Since 2012, CMS has operated the Medicare Prior Authorization of Power Mobility Device Demonstration in seven states:  California, Florida, Illinois, Michigan, New York, North Carolina, and Texas. CMS believes the demonstration project has been sufficiently successful and plans to extend it to an additional 12 states. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, and Washington.

CMS will also launch two new payment model demonstrations to test prior authorization for certain non-emergent services under Medicare. These services include hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transport. CMS hopes that information from these models, each being held in three states, will let officials fine-tune future policy decisions on the use of prior authorization in Medicare.

Finally, CMS has proposed to establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that it believes are frequently prescribed but unnecessary. Through a proposed rule, CMS is soliciting public comments on the process and criteria for selecting durable medical items subject to the new rules. The deadline to submit comments is July 28, 2014.

You can find additional information on CMS's prior authorizations initiatives on the CMS web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, June 20, 2014

Average family physician income up, but not equally

Family physician income, on average, has risen, but a new study indicates a greater number of family physicians are finding themselves on the low end of pay.

The 2013 Practice Profile Survey, a proprietary report issued in May, polled almost 500 American Academy of Family Physician (AAFP) members and found the average individual income in 2012 equalled $190,907. That's the highest average since the AAFP began surveying its members more than 30 years ago. However, the report noted that the median income was $170,000. A third of respondents said they earned $120,000 or less; a quarter of respondents said they earned more than $210,000.

"This suggests that the income levels among physicians are separating," the researchers wrote. "The separation is supported when the responses are categorized by income, as the percentage of respondents in the lowest category (earning $120,000 or less) was higher yet the mean income earned continued to grow."

When adjusted for inflation, the 2012 average still rises above previous years, but the median is similar.

Other survey findings include the following:

• Respondents said they worked an average of 48.3 hours a week in 2013, a decrease from 51.7 hours in 2012. Of that, they spent 34.1 hours in direct, face-to-face patient care, which was actually an increase from the previous year but similar to 2010 levels. The average amount of time spent on non-patient-care duties was down in 2013, falling to 2.6 hours per week, compared with 4.4 hours in 2012 and 4.8 hours in 2010.

• Sixty-eight percent of respondents said they were familiar with accountable care organizations (ACOs) and 28 percent said their practice was engaged in an ACO initiative. These are both increases over previous years as the ACO model continues to grow.

• Forty-two percent said they were familiar with the direct primary care (DPC) model. But only 2 percent of physicians said they currently worked in a DPC practice and 1 percent said they were transitioning to the DPC model.

• Twenty-six percent of respondents said their practice was recognized as a patient-centered medical home (PCMH), up from 24 percent the previous year. Nine percent said their practice had completed the transition and had applied for PCMH recognition. There was a slight decline in the percentage of physicians saying their practices received care management fees (44 percent), enhanced fee for service (37 percent), or shared savings amounts (13 percent) because of their inclusion in a PCMH. However, the percentage saying they received pay-for-performance amounts increased from 33 percent to 44 percent last year. Overall, 97 percent of respondents in a PCMH said their practice planned to reapply for PCMH recognition when the time came.

Tuesday, June 17, 2014

Potential pitfall in Medicare billing: office visits billed for hospital inpatients

This week, we conclude our series (see previous posts here, here, and here) on how to avoid common Medicare billing errors by focusing on billing the wrong kind of evaluation and management (E/M) code for patient visits provided in a hospital inpatient setting.

If you are rendering an E/M service to a patient in an inpatient hospital setting, then you should typically report that service with a CPT code from one of the following families:

•    99221-99223 – Initial hospital care
•    99231-99233 – Subsequent hospital care
•    99238-99239 – Hospital discharge services

Unfortunately, Medicare contractors are finding that physicians sometimes use a CPT code from the 99201-99215 family (Office or other outpatient services) for encounters with hospital inpatients. The example given is an 80-year-old female admitted to a hospital for an inpatient level of care on Oct. 17 and discharged on Oct. 20. A physician billed CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient) for the date of service of Oct. 18. Because Oct. 18 was during the inpatient hospital stay and the patient was not on a leave-of-absence from the hospital on that date, the contractor deemed the service an overpayment.

So, if you are billing E/M services for a patient in an inpatient hospital setting, then you need to use hospital visit codes to report those services and avoid office/outpatient visit codes for dates of service corresponding to the patient’s hospital stay.

For additional information, check out Medicare’s Evaluation and Management Services Guide and sections 30.6.9.1, 30.6.9.2, and 30.6.10 of chapter 12 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, June 10, 2014

Potential pitfall in Medicare billing: modifer misuse

Over the past two weeks, we have discussed how to avoid common Medicare billing errors recently identified by the Centers for Medicare & Medicaid Services (CMS). This week, we’ll focus on the pitfalls associated with a commonly used billing modifier.

There are times when family physicians do multiple, separate procedures on the same patient at the same session or on the same day, for which separate payment may be allowed. Medicare rules state that the second and any subsequent procedures are subject to reduced payment in this situation. Physicians are to identify such services by appending modifier 51 (multiple procedures) to the codes for the second and subsequent procedures. Medicare, in turn, reduces the payment allowance by 50 percent for codes with modifier 51 attached.

Unfortunately, the CMS has identified situations in which physicians are appending modifier 51 to a procedure code even when that procedure is the only one provided to the patient on that date. In those situations, the physicians are generating inappropriate underpayments of up to 50 percent and shooting themselves in the foot financially. The easy answer is to NOT append modifier 51 to any code in the surgery section of Current Procedural Terminology (codes 10021 to 69990) if that is the only code from that section provided to the patient on that date.

For further resources, CMS advises that you read section 40.6 of chapter 12 and section 30 of chapter 23 of the Medicare Claims Processing Manual. Next week, we’ll wrap up this series of posts by looking at the pitfalls associated with billing office visits for hospital inpatients.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, June 3, 2014

Potential pitfall in Medicare billing: preventive services

Last week, we began looking at some of the common Medicare billing errors identified by the Centers for Medicare & Medicaid Services (CMS) in its most recent Medicare Quarterly Provider Compliance Newsletter. This week, we’ll focus on another of those pitfalls, this one associated with Medicare-covered preventive services.

In recent years, the CMS has expanded Medicare coverage of preventive services to include many recommended with a grade of A or B by the United States Preventive Services Task Force. These services (and their corresponding Medicare billing codes) include:

•    Annual alcohol misuse screening, 15 minutes (G0442)
•    Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443)
•    Annual depression screening, 15 minutes (G0444)
•    Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes (G0446)

Unfortunately, Medicare contractors have determined that insufficient documentation is causing many improper payments for these services. “Insufficient documentation” in this context means that something was missing from the medical records, such as:

•    No record of the amount of time spent providing a timed service
•    No record of the billed service itself
•    No physician’s signature on the medical record

To avoid these potential problems, CMS advises physicians to:

•    Record start and stop times, or the total time spent, when providing a timed service
•    Sign entries in medical records at the time of service
•    Learn about the non-covered indications and frequency limits for preventive services under Medicare

To the last point, you should know that:

•    Screening for depression is not covered when performed more than once in a 12-month period
•    Alcohol screening is not covered when performed more than once in a 12-month period
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than once a day
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than four times in a 12-month period.

You can find additional information and links to other relevant resources in the newsletter. Next week, we’ll look at the pitfalls associated with misuse of a common coding modifier.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, May 30, 2014

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Four times a year, the Centers for Medicare & Medicaid Services (CMS) publishes its Medicare Quarterly Provider Compliance Newsletter, which seeks to help physicians avoid common Medicare billing errors. The latest issue highlights at least four errors that may be relevant to family physicians. This week, we’ll cover one related to psychotherapy provided in conjunction with an evaluation and management (E/M) service.

Family physicians are often the first point of contact for patients with mental health issues and sometimes provide psychotherapy to such patients in addition to an E/M service at the same encounter. Since January 2013, these services provided by the same provider on the same day are separately reportable and payable as long as they are significant, separately identifiable, and billed using the correct codes. In this situation, designated add-on codes are used to report psychotherapeutic services performed in addition to E/M codes.

Those CPT codes are:

•    +90833: Psychotherapy, 30 minutes with patient and/ or family member when performed with an E/M service
•    +90836: Psychotherapy, 45 minutes with patient and/ or family member when performed with an E/M service
•    +90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service

CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

•    90833: 16 to 37 minutes
•    90836: 38 to 52 minutes
•    90838: 53 minutes or longer

Psychotherapy sessions lasting less than 16 minutes are not separately reportable.

Documentation is crucial here. Time spent for the E/M service must be recorded separately from the time spent providing psychotherapy, and time spent providing psychotherapy cannot be used to meet criteria for the E/M service. Physicians can't enter one time period that includes both the E/M service and the psychotherapy.

CMS identified this blending of time periods as a common billing error in its quarterly newsletter. For example, a physician billed for a level 3 E/M service (99213) and 45 minutes of psychotherapy (90836). However, an authenticated printed visit note from the physician's electronic health record indicated total face-to-face time with the patient of 45 minutes and did not separately indicate the time spent providing psychotherapy services. The Medicare contractor, after an unsuccessful request for additional information, counted the claim as an overpayment due to insufficient documentation and recouped the payment from the physician.

Next week:  pitfalls associated with preventive services

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, May 29, 2014

Proposed delay but no reprieve for Meaningful Use

Health and Human Services (HHS) this month published a new proposed rule to its Meaningful Use program that would change what version of certified electronic health record technology (CEHRT) physicians must use and when they must attest for Stage 2. There are two groups of physicians that this new rule could affect:

All physicians attesting to Meaningful Use in 2014 – HHS proposes that if a physician has difficulty fully implementing a 2014 edition CEHRT because of a delay in availability in the market, they may use a 2011 edition CEHRT to attest to Meaningful Use in 2014.  The rule does not clarify what does and does not constitute a “delay in availability.” This may be clarified in the final version of the rule.

Physicians currently required to attest to Stage 2 – If you attested to Meaningful Use starting in 2011 or 2012, you were originally required to attest to Stage 2 of Meaningful Use this year. The proposed rule states that if you have difficulty fully implementing a 2014 edition CEHRT, you can (a) use a 2011 edition CEHRT to attest to Stage 1; (b) use a combination of 2011 edition and 2014 edition CEHRT to attest to either Stage 1 or Stage 2; or (3) still use a 2014 edition CEHRT and attest to Stage 2.

Be warned, however, that you will be required to complete your second year of Stage 2 attestation using a 2014 edition CEHRT starting Jan. 1, 2015. This means that although Stage 2 is delayed you do not have a reprieve to slow your implementation of a 2014 edition CEHRT. You will still need to perform the required Stage 2 activities at the first of the year.

The final tricky part is the federal rule-making bureaucracy. HHS must submit a notice of proposed rule making, which is what we are discussing now, before then requesting public comment, and then publishing a final rule. While it is extremely likely that this flexibility in using CEHRT and attesting to Stage 2 will be in the final rule, it may be changed by then. However, the marketplace asked for this flexibility, so it is hard to believe that the final rule would change dramatically.

– Steven E. Waldren, director of the Alliance for E-Health Innovation

Friday, May 23, 2014

Opportunity to review Open Payments data is approaching

The release in April of Medicare payments made to individual physicians caused its share of headaches and hand-wringing among practitioners who claimed that some of the information was incorrect or could be interpreted poorly by the public without the proper context.

Later this summer, another round of public filings could make life difficult. The Centers for Medicare & Medicaid Services (CMS) will begin releasing data from pharmaceutical and medical device manufacturers and group purchasing organizations on all financial interactions they've had with individual physicians and teaching hospitals.

Open Payments (you may remember it when it was called the Sunshine Act) is scheduled to release data for the final five months of 2013 by the end of September this year. Described as a way to provide more transparency to the financial relationships between physicians and their suppliers, the program tracks any payment or transfer of value of more than $10 from an applicable vendor to a physician. Beginning next year and thereafter, the Open Payments releases will cover an entire year.

Unlike the Medicare payments release, physicians will have a shot at reviewing the information submitted by manufacturers and attempting to correct any errors before publication.

Beginning June 1, eligible practitioners will be able to register for the CMS Enterprise Portal. This is considered the first step and must be completed before physicians, beginning in July, can register in the Open Payments system itself. That registration will gain the physician access to any manufacturer information reported about him or her, as well as allow the physician to dispute any payments he or she believes are inaccurate.

For more information on the Open Payments program, the CMS has a web site, complete with a downloadable user's guide.

Thursday, May 22, 2014

One-stop shopping Medicare quality reporting programs

One of the downsides to participating in multiple Medicare quality reporting programs, such as the Physician Quality Reporting System (PQRS) or Meaningful Use, is that you often have had to report the same data separately for each.

The Centers for Medicare & Medicaid Services (CMS) has heard your woes, however, and created a new interactive tool that will help you submit your quality data one time only and earn credit for multiple programs.

The “Reporting Once for 2014 Medicare Quality Reporting Programs” tool provides guidance based on how you plan to participate in PQRS in 2014:

•    As an individual eligible professional
•    As part of a group practice
•    As part of a Medicare Shared Savings Program Accountable Care Organization (ACO)
•    As part of a Pioneer ACO

Using the interactive tool, you will learn whether you will be eligible for PQRS incentives in 2014, will avoid PQRS Medicare penalties in 2016, and can satisfy the clinical quality measure component of the Medicare Electronic Health Record (EHR) Incentive Program. If you are part of a group practice with 10 or more eligible professionals, the tool will also help you assess the impact of your participation in PQRS on the Value-Based Payment Modifier.

You can use these streamlining options only if you have participated in the Medicare EHR Incentive Program for more than a year, and you are still required to report your core and menu objectives through the CMS Registration & Attestation System.

To use the interactive tool, simply click on the green “Start” button on page two of the tool. You can also use the “How to Report Once for 2014 Medicare Quality Reporting Programs” fact sheet  for an overview of the quality programs and reporting once in 2014.

For step-by step instructions for 2014 PQRS participation, view the PQRS How to Get Started web page on the CMS web site. If you have additional questions, contact the QualityNet Help Desk at 866-288-8912 or via qnetsupport@hcqis.org. The Help Desk is available Monday through Friday from 7:00 a.m. to 7:00 p.m. (Central Time).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 13, 2014

Time to register for the 2014 group practice reporting option (GPRO)

This blog recently discussed how to avoid a Medicare payment adjustment under the Physician Quality Reporting System (PQRS) in 2016. We'll focus on one of those methods, meeting the satisfactory reporting requirement for the group practice reporting option (GPRO), registration for which is now available under the 2014 PQRS.

The program defines a “group practice” as a physician organization with its own single tax identification number (TIN) and two or more eligible professionals (EPs) who have individual national provider identifiers and have reassigned their billing rights to the TIN. When your group is ready, you can register through the Physician Value-Physician Quality Reporting System (PV-PQRS) at http://portal.cms.gov. To choose your group's reporting mechanism, you will need a valid user identification and password for authorized access to the Centers for Medicare & Medicaid Services' (CMS). The registration system for the 2014 PQRS program will be open until Sept. 30.

GPRO participants who satisfactorily report data on PQRS measures during the 2014 reporting period (Jan. 1-Dec. 31) are eligible for a 0.5 percent incentive and will avoid the 2 percent pay cut in 2016. This is the last year that EPs can earn an incentive payment under PQRS.

The report those measures, GPRO participants can choose one of three mechanisms:

•    Qualified PQRS registry
•    Directly from an electronic health record (EHR) using certified EHR technology (CEHRT)
•    CEHRT via a data submission vendor

If your group has 25 or more EPs, you can also participate in GPRO via Web Interface. If the group practice has 25 or more EPs, then the group can elect to supplement its PQRS reporting mechanism with the Clinician and Group Consumer Assessment of Health Providers and Systems (CAHPS) survey. However, if the group practice has 100 or more EPs and has selected the Web Interface reporting mechanism for 2014, then the group is required to report the CAHPS survey.

Additional information about the 2014 GPRO registration and 2014 PQRS GPRO requirements is available on the CMS web site. For more information on how to register in the PV-PQRS Registration system, please visit the Self Nomination/Registration page. Finally, for questions about how to register, please contact the Quality Net Help Desk at 866-288-8912 (TTY: 1-877-715-6222), or by email: qnetsupport@hcqis.org.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 6, 2014

Update on ICD-10 delay

A previous post noted that the Protecting Access to Medicare Act of 2014, which was enacted on April 1, 2014, said that the Secretary of Health and Human Services (HHS) may not adopt ICD-10 before Oct. 1, 2015. The law, however, did not limit when the Secretary could adopt ICD-10 beyond that date.

Accordingly, the Centers for Medicare & Medicaid Services (CMS) announced last week that the Secretary of HHS expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning Oct. 1, 2015. The rule will also require Health Insurance Portability and Accountability Act covered entities to continue to use ICD-9 through Sept. 30, 2015.

CMS also announced that it has canceled the ICD-10 end-to-end testing that it otherwise planned to conduct during the week of July 21. CMS canceled the July testing due to the ICD-10 implementation delay and said additional opportunities for end-to-end testing will be available in 2015.

Meanwhile, the acknowledgment testing that occurred in March was apparently a success. CMS previously reported that from March 3 to March 7 they received approximately 127,000 ICD-10 acknowledgment test claims, representing about 5 percent of those who submit claims to Medicare. CMS and its contractors encountered no systems problems associated with those test claims. CMS had originally planned to offer another week of acknowledgment testing this month; there is no word yet on whether it will still do so or postpone that to 2015 as well.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, May 1, 2014

Acting now to avoid a PQRS payment adjustment in 2016

While 2016 is more than a year and a half away, what you do in 2014 will determine whether or not you are subject to a Medicare payment adjustment under the Physician Quality Reporting System (PQRS) in 2016. In essence, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (Jan. 1-Dec. 31, 2014):

  • If participating as an individual eligible professional: Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive. Or, participate in PQRS via qualified clinical data registry, qualified registry, or claims reporting and report at least three measures covering one National Quality Strategy (NQS) domain for at least 50 percent of your Medicare Part B fee-for-service (FFS) patients.

  • If participating as a group practice: Meet the Group Practice Reporting Option requirements for satisfactory reporting. Or, participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.

More information is available via the PQRS web page on the Centers for Medicare & Medicaid Services' website. You may especially want to look at their new fact sheet for guidance on how to avoid the 2016 PQRS payment adjustment. You can also contact the QualityNet Help Desk 7 a.m.-7 p.m. (Central Time), Monday through Friday, by calling 866-288-8912 (TTY: 877-715-6222) or by sending an email to qnetsupport@hcqis.org.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, April 22, 2014

Dealing with the opportunities and threats of the new Medicare data release

This month's release by the Centers for Medicare & Medicaid Services (CMS) of a public use file on Medicare physician utilization and payment data creates both opportunities and threats for family physicians. We're going to consider both.

On the plus side, the release of the Medicare data provides a great opportunity for the family medicine community to highlight the complexity of care that family physicians provide. Also, the data show wide variation in total payments made among various medical specialties, which reinforces the point that primary care physicians are underpaid relative to other specialists and sub-specialists. When that data set is further studied, it may make the case that family physicians, who provide comprehensive and time-intensive health care to their patients, are undervalued from a payer perspective.

On the other hand, the Medicare data set has lots of limitations. For example, physicians weren't given an opportunity to review the data for potential errors; the data don't measure the quality of care provided; there's no allowance for residents or nurse practitioners filing claims under a physician's national provider identifier, meaning the payment numbers could be inflated; Medicare payments may not always cover the costs of treatment, which makes the numbers an inaccurate portrayal of physician compensation; the data are not risk-adjusted, don't account for patient mix or include care for private insurance patients or Medicaid beneficiaries; the numbers don't reflect the often higher reimbursements provided in facility settings versus a physician's office; and they don't consider changes in Medicare's coding and billing rules that may different over time and across regions of the country.

Those weaknesses presents several threats:

•    Insurers, hospitals, and accountable care organizations could use the data to assess physicians’ charges and potentially drop those individuals deemed to be high-cost physicians.
•    Public and private insurers might use the data as a reason to impose additional prior authorization requests for expensive Part B drugs.
•    The data set has the potential to paint a negative picture of some physicians with patients, and it also has the potential to further enhance the perception that physicians are overpaid relative to the average U.S. worker.

Finally, the data may generate some difficult questions from patients or local media. Here are some points to emphasize if you find yourself in such a conversation:

•    Greater transparency in the health care system is a laudable goal, and there is potential value in the release of Medicare payment data for ensuring the quality of care for patients and efficient use of resources in the delivery of health care services.
•    Release of this data shines a light on the need to reform physician payment away from fee-for-service and toward payment for quality of care.
•    Data should include context and background on physician payments so that policy makers, patients, and the public understand the overall quality of care their physicians provide.
•    The data release still needs safeguards to ensure that neither false nor misleading conclusions are derived from this information, which has its limitations.
•    Medicare payment information by itself does not describe a physician’s practice.
•    Hopefully, researchers will use this data to understand and improve how health care dollars are spent, so that we can also improve the health of patients, families, and communities.

Whether the potential opportunities outweigh the potential threats remains to be seen. However, knowing what they are provides a starting point for trying to maximize the former while minimizing the latter. For more information on this subject, check out the AAFP's "Physician Payment Transparency" web page and read the frequently asked questions on the CMS website.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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