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Friday, April 24, 2015

Reminder: CMS will soon require enrollment for Part D prescribing

As we first noted last December, the Centers for Medicare & Medicaid Services (CMS) this year will begin requiring physicians who write prescriptions for Medicare Part D drugs to be either enrolled in Medicare or have a valid record of opting out.

We also noted that while the new policy is effective June 1, CMS has delayed enforcement until Dec. 1. If you aren’t currently enrolled in Medicare or do not have a valid opt-out affidavit on file you should submit an enrollment application or opt-out affidavit to your Part B Medicare Administrative Contractor by June 1. This will ensure that CMS has enough time to process the paperwork ahead of the Dec. 1 deadline and make sure your patients don’t have their Part D prescription drug claims denied.

To prepare prescribers and Part D sponsors for enforcement, CMS is using an online file to identify physicians and eligible professionals who are enrolled in Medicare in an approved or opt out status. The first iteration of the enrollment file is now available. CMS will update the enrollment file every two weeks through the Dec. 1 enforcement date.

Note that enrollment is not the same as participation. A physician can enroll in Medicare without being a “participating” physician.

For more information, including how to enroll online, CMS has published an article, “Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D,” through its MLN Matters information service. You can also find more information on the “Prescriber Enrollment Information” web page on the CMS web site.   

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

Wednesday, April 22, 2015

Physician compensation rises but so do frustrations

Most primary care and other medical specialties saw a modest gain in overall compensation last year, although many physicians are still unhappy with the state of medicine.

More than 19,000 physicians in 25 specialties were surveyed for the Medscape Physician Compensation Report for 2015 released this week. It showed that the average compensation for primary care physicians held steady at $195,000 in 2014 while other specialties reported an average of $284,000. Family medicine led the gains for primary care, increasing 10 percent over 2013 to $195,000. Internal medicine and pediatrics each gained 4 percent to $196,000 and $189,000, respectively.

While the pay is up, only 47 percent of primary care physicians and 48 percent of family physicians said they felt they were fairly compensated, compared with half of specialists. Also, while almost three-fourths of family physicians surveyed said they would again choose medicine as a career if they had it to do over, less than a third said they would stick with family medicine.

The trend of physicians choosing to work for hospitals and other large health care groups continued with 63 percent of survey responders saying they were employed while 32 percent said they remained in private practice. Employed primary care doctors appeared to be trading some compensation for the security and fewer regulatory headaches of employment as they made an average of $189,000 versus the $212,000 earned by self-employed physicians.

The wage gap between male and female physicians appears to be shrinking, albeit slowly. Male physicians made an average of $284,000, or 24 percent more than female physicians ($215,000). The difference was 28 percent when Medscape measured in 2011. The researchers suggested much of the difference in compensation levels comes from female physicians typically working fewer hours and weeks and tending to go into lower-paying specialties such as obstetrics/gynecology or pediatrics.

There has been a lot of focus on physicians moving to alternative practice styles, but real-world results are mixed. Just 3 percent of surveyed physicians said they were in a concierge practice, which typically charges an annual retainer, and 5 percent said they were in a cash-only practice, down from 6 percent in 2013. Thirty-seven percent said they were participating in or planning to participate in an accountable care organization (ACO), which can reward physicians and allied health care groups for lowering costs and improving care.

Primary care physicians are apparently more open to these new practice models with 4 percent in concierge practices, 5 percent in cash-only practices, and 43 percent in or planning to join an ACO.

To learn more about some of these subjects, visit the following FPM topic collections:

Thursday, April 16, 2015

Sustainable growth rate repeal: Now what?

As noted earlier this week, Congress has enacted the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA). This legislation repeals the sustainable growth rate and negates a 21.2 percent cut in Medicare physician payments that technically went into effect for dates of service on or after April 1. President Obama is expected to sign the bill. MACRA will have a significant impact on Medicare physician payment for years to come, but what does it mean for your practice in the short run?

MACRA maintains the pre-April 1 rate for dates of service through June 30. For dates of service from July 1 through Dec. 31, Medicare payments will increase by 0.5 percent. For 2016, the Medicare payments increase another 0.5 percent.

To minimize financial headaches for physicians, the Centers for Medicare & Medicaid Services (CMS) had agreed to wait 10 business days before processing all affected claims with dates of service on or after April 1. CMS has now instructed the Medicare Administrative Contractors (MACs) to implement the rates contained in MACRA; however, the MACs probably will still process a small number of claims using the reduced rate before they can adjust their claims payment systems. These will likely be claims for dates of service early in April. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate, and you don't have to do anything if you have already submitted claims that fall on the affected dates.   

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

Wednesday, April 15, 2015

Medicare legislation repeals flawed physician payment formula, avoids cuts

Last night, the U.S. Senate voted 92-8 to repeal the sustainable growth rate formula that is used to calculate Medicare physician payment rates. The vote prevents a looming 21.2 percent cut for physicians and ends 12 years of perennial short-term fixes by Congress. The House passed the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 last month, also by an overwhelming margin. President Obama has said he will sign the bill into law.

In addition to preventing the payment cut and ensuring annual positive or flat fee updates for 10 years, the legislation, also known as MACRA, establishes new payment options that offer incentives to physicians who participate in alternative payment models. Those who remain in the fee-for-service system and meet certain performance benchmarks may also earn incentive payments.

MACRA also extends funding by two years for CHIP and other programs of importance to family medicine. Additional information about the legislation is available on the AAFP website, and additional details will be available as the regulations are developed.  

Friday, April 10, 2015

CMS sees ICD-10 claims acceptance rate rise in latest test

The Centers for Medicare & Medicaid Services (CMS) continues to rack up what it characterizes as successful tests of handling claims with ICD-10 codes.

CMS says 775 physicians and other providers submitted almost 9,000 claims during acknowledgement testing last month, and CMS accepted 91.8 percent of those claims. That is a higher acceptance rate than during acknowledgement testing weeks in November (76 percent) and March 2014 (89 percent).

The rejected claims included a number of user errors, such as using an invalid National Provider Identifier (NPI) or an NPI that wasn’t on the NPI crosswalk, using an invalid HCPCS code or postal ZIP code, or using service dates in the future. CMS said the tests revealed no problems in the fee-for-service billing system itself.

“Testing demonstrated that CMS is ready for ICD-10 and shows the tremendous progress of health professionals to be ready for the transition,” the agency said.

Physicians and other providers must switch to using ICD-10 codes beginning Oct. 1 of this year.

Acknowledgement testing, which ensures that the claim is received and then accepted or rejected, differs from end-to-end testing, which continues the test through to the submitter receiving an accurate remittance advice. CMS is completing end-to-end testing from April 27 to May 1 and from July 20 to July 24.

The final scheduled acknowledgement testing period is June 1-5. Physicians and other providers can conduct acknowledgement testing on their own at any time. You can contact your Medicare Administrative Contractor for more information.

For more information, check out the following Medicare Learning Network (MLN) articles:

•    “FAQs – International Classification of Diseases, 10th Edition (ICD-10) Acknowledgement Testing and End-to-End Testing"

•    “ICD-10 Testing - Acknowledgement Testing with Providers

•    “Medicare FFS ICD-10 Testing Approach

Tuesday, April 7, 2015

Open Payments review period begins

The Centers for Medicare & Medicaid Services (CMS) this week kicked off a 45-day review and dispute period for its Open Payment system (formerly known as the Sunshine Act).

During this process, physicians and teaching hospitals have a chance to look at financial information reported about them by pharmaceutical and medical device manufacturers and group purchasing organizations and point out any errors before CMS makes the information publicly available on June 30. After the review period ends, the CMS will continue to review disputed payments but won’t update the public records until next year.

This is the second year for Open Payments, and the records will cover payments made to physicians and teaching hospitals in 2014.

The review process is voluntary, but to participate and file disputes, you will need to register in both the CMS Enterprise Identity Management System (EIDM) and the Open Payments system itself.

If you registered last year, you don’t have to register again. Just go to the CMS Enterprise Portal, log in using your user ID and password, and navigate to the Open Payments system home page.

Note, however, that the CMS Enterprise Portal locks your account if there has been no activity for 60 days or more and deactivates it if there has been no activity for 180 days or more. If your account is locked, go to the CMS Enterprise Portal, enter your user ID and answer all challenge questions, and you’ll  be asked to reset your password. To reinstate a deactivated account, contact the Open Payments Help Desk at openpayments@cms.hhs.gov.

CMS is also holding a national provider call discussing the review period, entitled “Open Payments (Sunshine Act) 2015: Prepare to Review Reported Data – Registration Now Open.” The call is scheduled from 2 p.m. to 3:30 p.m. (EDT) on Wednesday, April 15. To register – and CMS says space may be limited – go to the CMS web page for upcoming calls.

CMS has more information, including educational materials, on its Open Payments website. It also can field questions during normal business hours at openpayments@cms.hhs.gov or by calling 1-855-326-8366.

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

Friday, April 3, 2015

CMS looks for ICD-10 testing volunteers in July

The Centers for Medicare & Medicaid Services (CMS) is continuing to look for problems in its billing and claims systems in advance of the switch to ICD-10 coding in October.

CMS in January completed a round of end-to-end testing that showed there were a few lingering problems but the vast majority of physicians filing claims in the test were getting paid.

That said, the agency is holding two more rounds of end-to-end testing from April 27 to May 1 and from July 20 to July 24. CMS has already selected its volunteer providers for the test later this month but is still taking applications for the summer, which is so far the last round of scheduled end-to-end testing before the changes go forward.

Around 850 physicians and other providers will participate in the test, submitting claims in combination with Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractor.

If you would like to volunteer, application forms are available from your MAC and are due April 17. The MACs and CEDI will notify eligible volunteers by May 8 with additional instructions. If you participated in the January test or are participating in the test this month, you can participate in the July test without reapplying.

For more information, download the following Medicare Learning Network (MLN) articles:
“ICD-10 Limited End-to-End Testing with Submitters for 2015,”
“FAQs – ICD-10 End-to-End Testing,”
“Medicare FFS ICD-10 Testing Approach.”

Tuesday, March 31, 2015

HHS launches network to encourage value physician payments

Last week, the U.S. Department of Health and Human Services (HHS) launched the Health Care Payment Learning and Action Network. HHS intends for the network to work with private payers, employers, consumers, providers, state Medicaid programs, and others to expand the use of alternative payment models.

According to HHS, the network will:

•    Facilitate the joint implementation and expansion of new payment and care delivery models,
•    Identify ways to implement and report on these new payment models,
•    Collaborate to generate evidence, share approaches, and remove barriers,
•    Develop common approaches to such core issues as beneficiary attribution, financial models, benchmarking, quality and performance measurement, and risk adjustment, and
•    Create implementation guides for payers, purchasers, providers, and consumers.

HHS believes the network is key to the agency’s initiative to move the Medicare program, and the health care system at large, toward paying providers based on the quality of care they give patients, rather than the quantity. HHS highlighted that initiative in January when HHS Secretary Sylvia Burwell announced the goal of moving 30 percent of Medicare payments into alternative payment models by the end of 2016 and 50 percent into alternative payment models by the end of 2018. Alternative payment models include accountable care organizations, bundled payments, and advanced primary care medical homes. Overall, HHS seeks to have 85 percent of Medicare payments tied to quality or value by 2016 and 90 percent by 2018.

Anyone is welcome to join the network, and all interested individuals and organizations can register online. More information is available on the network’s web page.

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

Thursday, March 26, 2015

Congress races calendar to repeal Medicare pay cut

Update: On April 14, Congress enacted the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA), repealing the sustainable growth rate and negating the 21.2 percent cut in Medicare physician payments that technically went into effect for dates of service on or after April 1.


Barring a legislative fix by Congress, Medicare physician fees are scheduled to begin shrinking next week. But it’s likely physicians won’t feel the pinch immediately – and possibly never again.

Current law requires the Centers for Medicare & Medicaid Services (CMS) to cut Medicare physician payments by 21.2 percent effective with dates of service on or after April 1. CMS said the payment cut wouldn’t affect Medicare physician fee schedule claims for services rendered on or before March 31, which will be processed and paid under normal procedures and time frames.  

To avoid the cut or yet another patch to the payment system, Congress is working to repeal the sustainable growth rate (SGR) formula, a portion of the law that has threatened drastic reductions in Medicare fees for years. On Tuesday, members of the House of Representatives unveiled a bipartisan package to repeal the SGR formula, which the House then approved Thursday. The package now goes to the Senate, where its future is uncertain. The AAFP and others are encouraging their members to contact their members of Congress in support of SGR repeal.

In the meantime, expect CMS to do what it can to give Congress some breathing room. Under current law, it takes at least 14 calendar days for Medicare to pay electronic claims once they are received (at least 29 days for paper claims). In the past, CMS has ordered its contractors to hold Medicare claims for part of this statutory payment window to give Congress more time to act and thus avoid processing claims at a discounted rate that is later overturned. It seems reasonable to expect CMS will do something similar this time if Congress does not act by April 1.

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

Thursday, March 19, 2015

ICD-10 test identifies problem with remittance advice

Some more information about Medicare’s January end-to-end testing of the upcoming switch to ICD-10 coding: About 6 percent of the test claims couldn’t generate a remittance advice for the testing health care provider.

The Centers for Medicare & Medicaid Services says its ICD-10 system generated remittance advice letters for the vast majority of test claims. It blamed the rare miscues on technical problems in the Medicare Administrative Contractors (MACs) testing environments and said that some of the problems were not connected to ICD-10 coding.

Physicians and other providers who didn’t get a remittance advice in January will be able to resubmit those claims during the upcoming end-to-end testing weeks in April and July.

CMS said the MACs are setting up their systems for the next test and are expected to resolve all of the technical issues by then. Physicians and other providers must switch to ICD-10 coding on Oct. 1.

If you would like to participate in the July 20-24 end-to-end test, volunteer forms are due April 17. Those forms are available through your local MAC.

If you want to learn more about how to code using ICD-10, this collection of ICD-10 articles from Family Practice Management can help.

Thursday, March 12, 2015

CMS reveals results of Value Modifier program's first year

The Center for Medicare & Medicaid Services (CMS) has gotten back the results of the first year of the Value-based Payment Modifier program and recently blogged about them.

The Value Modifier, included in the Affordable Care Act, is intended to encourage physicians and practice groups to provide high quality and cost-effective care. While it will eventually apply to all health care practitioners in the country, the Value Modifier is being phased in gradually and applied only to groups of 100 or more eligible professionals in 2015. Those groups that met at least minimum standards were given the option of electing “quality-tiering,” which boosts, cuts, or leaves stable those physicians’ Medicare payments based on how they performed against national quality and cost benchmarks in 2013. Those who met minimum standards but did not elect quality-tiering – 564 groups – were not subject to any adjustments this year based on their performance.

According to CMS, nearly 7,000 physicians in 14 group practices across the country are receiving an increase in their Medicare payments in 2015 as a result of this quality-tiering. The group practices receiving increases fell into two categories:

1.    Groups that produced high quality care at average cost (the majority of groups receiving increases).
2.    Groups that produced average quality care at lower-than-expected cost.

Physician groups getting increases had, on average, better hospital readmissions rates –14.3 per 100 admissions – than the national benchmark of 16.4. These groups also had, on average, lower hospital admissions rates for acute and chronic ambulatory care sensitive conditions. Another 102 groups electing quality-tiering will see no change either because they met the national benchmarks or there was insufficient data.

Meanwhile, 330 groups are slated to see their Medicare payments cut in 2015 because of the Value Modifier program. Eleven groups subjected themselves to quality-tiering but failed to meet national benchmarks for quality or cost. Another 319 failed to meet the minimum requirements of the program and didn't have an option to elect quality-tiering.

Beginning in 2016, the Value Modifier will apply to groups with at least 10 or more eligible professionals, and quality-tiering will automatically apply to all of them. In 2017, the Value Modifier will apply to all groups and to solo practitioners who are physicians. Beginning in 2018, CMS will apply the Value Modifier to non-physician eligible professionals as well.

Physician groups and physicians can find information about their quality and cost performance in their Quality Resource and Use Reports  that were made available last fall.

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

Thursday, March 5, 2015

Physicians get a little more time for PQRS reporting

Some physicians are getting more time to submit 2014 data for the Physician Quality Reporting System (PQRS). Last week, the Centers for Medicare & Medicaid Services (CMS) announced it was giving physicians until 8 p.m. (Eastern Time) on March 20 (up from Feb. 28) to report their information if they were using either of these reporting methods:

•    A Direct Electronic Health Record (EHR) product or Data Submission Vendor using certified EHR technology
•    Qualified clinical data registries reporting for PQRS and components of meaningful use for the Medicare EHR Incentive Program

Individual eligible professionals (EPs) and group practices using these reporting methods to participate in other CMS programs, such as the Medicare EHR Incentive Program and Comprehensive Primary Care Initiative, can follow the new deadline as well. In addition, March 20 is the new deadline for eligible professionals wanting to attest to meaningful use for the 2014 EHR reporting period in the Medicare Electronic EHR Incentive Program.

Physicians who satisfy the PQRS reporting requirements for 2014 earn an incentive payment while those who don’t face a penalty on all Medicare Part B physician fee schedule services provided in 2016. For questions, please contact the Quality Net Help Desk at 866-288-8912 or by email at qnetsupport@hcqis.org from 7 a.m.-7 p.m. Central Time.

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

Monday, March 2, 2015

CMS says ICD-10 billing system test successful

The Centers for Medicare & Medicaid Services says a recently completed end-to-end test shows its billing systems are prepared for the switch to ICD-10 in October.

Between Jan. 26 and Feb. 3, 661 physicians, other health care providers, and billing companies volunteered to send test claims to the Medicare Administrative Contractors (MACs) and the Durable Medical Equipment MAC Common Electronic Data Interchange (CEDI) contractor. Unlike ICD-10 acknowledgement testing, which simply determines if the tester’s claim is accepted or rejected, the end-to-end tests process the claims through all Medicare system edits and provide an Electronic Remittance Advice.

Of the total 14,929 test claims, Medicare’s billing system accepted 12,149, or 81 percent. CMS said in a news release that most of the rejected claims failed for technical reasons, such as using an incorrect National Provider Identifier (NPI) number, using a date of service outside the study range, or submitting an incorrect ICD-10 code. The agency said it found and will address a system issue that caused a handful of home health claims to process incorrectly. But officials said they found no issues affecting front-end CMS systems for professional and supplier claims.

“Testing demonstrated that CMS systems are ready to accept ICD-10 claims,” CMS said.

CMS is planning two more end-to-end tests this year. While the agency has already chosen volunteers for the April 27-May 1 test, it is still looking for providers to test the system July 20-July 24. Volunteer forms will be made available at MAC and CEDI websites on March 13.

For more information, download the following Medicare Learning Network (MLN) articles:
“ICD-10 Limited End-to-End Testing with Submitters for 2015,”
“FAQs – ICD-10 End-to-End Testing,”
“Medicare FFS ICD-10 Testing Approach.”

Tuesday, February 24, 2015

Another opportunity for ICD-10 acknowledgement testing

The Centers for Medicare & Medicaid Services (CMS) is offering acknowledgement testing next week (March 2-6) to help physicians prepare for the transition to ICD-10 this fall.

Registration is not required, and any provider who submits claims electronically can participate. Participants, which include Medicare claims clearinghouses, will have access to real-time help desk support through their Medicare Administrative Contractors (MACs) and the Durable Medical Equipment MAC Common Electronic Data Interchange (CEDI) contractor. CMS will be also analyze the testing data. Information on how to participate is available on local MAC websites or through a clearinghouse, if the practice uses a clearinghouse to submit Medicare claims.

Here’s what physicians can expect during testing:
•    Test claims will receive the 277CA or 999 acknowledgement, as appropriate, to confirm that the claim was accepted or rejected in the system.
•    Test claims will be subject to all current front-end edits, including edits for valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and codes, including Healthcare Common Procedure Coding System (HCPCS) and place of service.
•    Testing will not confirm claim payment or produce a Remittance Advice.
•    MACs and CEDI will be staffed to handle increased call volume during this week.

CMS offers the following testing tips:
•    Make sure test files have the "T" in the ISA15 field to indicate the file is a test.
•    Send ICD-10 coded test claims that closely resemble the claims that the practice currently submits.
•    Use valid submitter identification, NPI, and PTAN combinations.
•    Use current dates of service on test claims (i.e., Oct. 1, 2014 through Mar. 1, 2015); do not use future dates of service or the claim will be rejected.
•    Use ICD-10 companion qualifier codes when submitting ICD-10 diagnosis codes.

If a physician is not prepared to do ICD-10 acknowledgement testing next week, CMS is planning another dedicated test June 1-5. In the meantime, practices can do acknowledgement testing on their own anytime up to the Oct. 1 implementation date.

For more information, check out the following Medicare Learning Network (MLN) articles:
•    “FAQs – International Classification of Diseases, 10th Edition (ICD-10) Acknowledgement Testing and End-to-End Testing"
•    “ICD-10 Testing - Acknowledgement Testing with Providers
•    “Medicare FFS ICD-10 Testing Approach

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

Monday, February 23, 2015

CMS continues addressing questions about CCM

Last week, the Centers for Medicare & Medicaid Services (CMS) hosted a national provider call on payment of chronic care management (CCM) services, codes for which went into effect this year. The call reaffirmed a lot of what CMS has previously stated in the Federal Register and that the AAFP has summarized on its web site.

One new piece of information gleaned from the call is the fact that rural health clinics and federally qualified health centers are not authorized to bill Medicare for CCM at this time. CMS staff indicated that they hope to change that in 2016. On the call, CMS staff also highlighted that they have published a fact sheet on CCM.

For those who missed the call, an audio recording and written transcript of it will be posted in approximately two weeks. A copy of the slide presentation used during the call is already available.

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

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