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Monday, February 29, 2016

CMS beefing up screening of Medicare-enrolled providers

To help combat Medicare fraud – and weed out those most responsible for it – the Centers for Medicare & Medicaid Services (CMS) is making changes in how providers enroll and remain in the Medicare system.

CMS plans to publish a new rule in the Federal Register tomorrow that creates added requirements for those enrolling to become Medicare providers and gives the agency tools to find and terminate enrolled providers who have shown a history of fraud. This has added significance as many physicians are coming up on the end of their five-year Medicare revalidation cycle and will be submitting information to maintain their billing privileges.

Among the changes:
• Providers would have to disclose connections to other providers or suppliers who have had their Medicare, Medicaid, or CHIP enrollment denied or revoked; have uncollected debt to those programs; or have had their payment suspended under a federal health care program or because of an Office of Inspector General exclusion.
• CMS could deny or revoke Medicare enrollment if it discovered a provider's Medicare enrollment has been revoked under a different name or identity. Also, it could deny or revoke Medicare enrollment if a provider’s license has been revoked in one state and he or she is applying or enrolled in a different state or if the provider has been terminated from a state Medicaid or other federal health care program under a current or different name or identity.
• The agency could revoke the physician's enrollment for what CMS considers an "abusive" or dangerous pattern or practice of ordering, referring, certifying, or prescribing Medicare Part A or B services, items, or medications.
• The length of time someone can be barred from re-enrolling in Medicare would increase, including a maximum 20-year ban for a second revocation.
• CMS would require that physicians and others who order, certify, refer, or prescribe any Part A or B service, item, or medication must be either enrolled in Medicare or have a valid opt-out.

Meanwhile, CMS is boosting its existing methods for screening Medicare providers by increasing site visits to Medicare-enrolled providers, replacing the current Provider Enrollment Chain and Ownership System (PECOS) with software that can also look for invalid addresses, and deactivating on a monthly basis enrolled providers who have not billed Medicare in the last 13 months.

The upshot is that while physicians have always needed to be careful when submitting documentation to accept Medicare patients, you may now need to increase those efforts, even if you don't have any Medicare skeletons lurking in your past.

Monday, February 22, 2016

New insurer database tool could cut back on phone calls to physicians

The Council for Affordable Quality Healthcare (CAQH) has created a centralized way for physicians to update their information in insurance plan directories and reduce the amount of time they spend talking to insurance companies.

The nonprofit alliance of insurers and health care providers has created DirectAssure, a database that coordinates with CAQH’s current ProView tool used by more than 800 health plans for such things as credentialing.

CAQH said it will contact physicians designated by participating health plans at least once a quarter to ask them to review and update their information. Physicians can then log on to the system for free and update their location, contact information, specialty, and group/institution affiliation, as well as whether they’re accepting new patients.

CAQH said the health plans can check the DirectAssure system to make sure their directories are correct, instead of a physician receiving several calls from the plans themselves.

Besides making things easier for physicians, the new system is aimed at meeting new federal and state requirements that health plans do a better job of keeping their provider databases current and accurate and more useful to patients.

Tuesday, February 16, 2016

Medicare: Physicians are mixing up E/M codes for skilled nursing facilities

It seems there’s room for improvement in how many physicians code for evaluation and management (E/M) services provided to patients in skilled nursing facilities (SNFs).

The Centers for Medicare & Medicaid Services (CMS) recently said its auditors found that physicians and non-physician practitioners (NPPs) are reporting incorrect codes for E/M services provided to SNF Medicare patients.

Specifically, physicians and NPPs are using CPT codes 99221-99223 (initial hospital care), 99231-99233 (subsequent hospital care), and 99238-99239 (hospital discharge day management) to bill for E/M services supplied to SNF patients. However, those codes are for E/M services supplied to hospital patients.

As described in the Medicare Claims Processing Manual Section 30.6.13, E/M services provided to patients residing in an SNF must be reported using the appropriate CPT level of service code within the range identified for initial nursing facility care (99304-99306) and subsequent nursing facility care (99307-99310). The annual nursing facility assessment is billed using CPT code 99318, and SNF discharge services are billed using CPT codes 99315-99316. Using an inpatient hospital E/M CPT code represents inappropriate billing when you render E/M services in an SNF.

Part of the confusion may stem from the fact that the patients in question are in hospital “swing beds,” which can represent either inpatient hospital or nursing facility care, depending on how the hospital is billing Medicare for its services. Section 30.6.9.D of the Medicare Claims Processing Manual advises that if the hospital is billing Medicare for the patient’s inpatient care as inpatient hospital care, the hospital care CPT codes apply for purposes of reporting physician services to the patient. If the hospital is billing Medicare for the patient’s inpatient care as nursing facility care, then the nursing facility CPT codes apply for physician services. So, if in doubt about the status of a Medicare patient in a “swing bed,” check with the hospital regarding how it is billing Medicare for the patient’s inpatient care and adjust your coding accordingly.

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

Monday, February 15, 2016

CMS gives physicians more time to attest to 2015 meaningful use

The Centers for Medicare & Medicaid Services (CMS) has extended the attestation deadline for the meaningful use program. Eligible Professionals (EPs) now have until 11:59 PM ET on Friday, March 11, to attest to the 2015 reporting year. The previous deadline was Feb. 29. Failure to attest will result in a 3 percent cut to your 2017 Medicare Part B payments.

EPs must attest to a continuous 90-day period between Jan. 1, 2015, and Dec. 31, 2015. Those scheduled to attest to Stage 2 will report on 10 objectives, while EPs scheduled to attest to Stage 1 will have alternate measures and exclusions available to them for 2015. Attestation is completed through the online Registration and Attestation System. You must have a National Plan and Provider Enumeration System (NPPES) web user account to log on. If someone is attesting on your behalf (such as a practice administrator) that individual must have an Identity and Access Management web user account and must be granted the appropriate authorizations to complete the attestation.

This announcement is the latest of many regarding meaningful use in recent months. In October, CMS released a final rule that, among other things, condensed Stages 1 and 2 into Modified Stage 2 and announced the Stage 3 objectives. Last month, CMS was granted the authority to streamline its exception process. Providers have until March 15 to submit a hardship application to avoid the 2017 payment adjustment. Also in January, acting administrator Andy Slavitt announced that the meaningful use program will be ending as a standalone program as the Medicare Access and CHIP Reauthorization Act (MACRA) is implemented in 2019.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Friday, February 12, 2016

CMS finalizes rule for returning Medicare overpayments

It’s been four years since the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for how physicians should identify and return Medicare overpayments. The Feb. 11 release of the final rule, which pertains to overpayments involving Medicare Part A and Part B, was delayed by the complexity of the issue and the volume of comments received, CMS said.

The Affordable Care Act and now the CMS rule requires physicians to report and return overpayments within 60 days of identifying them. Failure to return them could lead to prosecution under the False Claims Act, including fines and financial damages. 

The rule defines “identification” of an overpayment as when the physician “has or should have, through the exercise of reasonable diligence, determined that (they have) received an overpayment and quantified the amount of the overpayment.” The exact moment when the 60-day clock starts had been the subject of legal action in recent years.

The final rule also specifies that physicians are liable for overpayments going back six years. This period is shorter than the proposed 10-year period, which attracted opposition from several physician groups who said that would create a significant burden in terms of record retention.

CMS estimates the annual cost to all health care providers of complying with the new rule will range between almost $121 million and $201 million.

Tuesday, February 9, 2016

CMS encourages you to register now to review “Open Payments” later

The Centers for Medicare & Medicaid Services (CMS) has given members of the health care industry until March 31 to submit information on all payments and “transfers of value” they made to physicians and teaching hospitals in 2015.

Under the “Open Payments” program, the information from pharmaceutical and medical device manufacturers and group purchasing organizations will be compiled and released later this year in a database available to the public.

Once the information is submitted, physicians and teaching hospitals can review any payments or transfers of value attributed to them and dispute items they believe are incorrect before the database is made public. But to do so, physicians must register in the Open Payments system.

If you registered last year, you are not required to do so again. However, if it has been more than 180 days since you logged onto the Enterprise Identity Management System, the account has been deactivated for security purposes.

You can visit the Open Payments Resources webpage for more information, including a fact sheet for physicians. For questions, you can contact the related Help Desk at 855-326-8366, Monday through Friday, from 7:30 a.m. to 6:30 p.m. CT.

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

Friday, February 5, 2016

Diabetes foot exams among changes in 2016 PQRS

The 2016 version of the Physician Quality Reporting System (PQRS) included a number of changes, but the revised diabetes foot exam is especially important to note because it requires more work than the measure it replaced.

The previous measure, “Diabetes: Foot Exam,” asked for a visual inspection of the foot along with a sensory exam using a monofilament and a pulse exam. The new measure, “Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation,” specifies that the sensory exam include a monofilament plus one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexed, or vibration perception threshold. This exam only needs to happen once a year, but it is important to document correctly.

In addition, the new measure, with some exceptions, applies to all patients with diabetes over the age of 18. The previous measure covered patients ages 18-75.

Remember, physicians who do not meet PQRS requirements in 2016 face a 2-percent cut in Medicare payments in 2018.

– Amy Mullins, MD, Medical Director of Quality Improvement, American Academy of Family Physicians

Tuesday, February 2, 2016

CMS aligning Medicaid and Medicare home health requirements

Last week, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that adds new requirements for Medicaid home health services. Among the new requirements is that physicians document a face-to-face encounter with Medicaid patients before ordering the home health services or certain related medical equipment. This rule aligns Medicaid with similar regulatory requirements for Medicare.

Specifically, the final rule requires that when first ordering home health services (nursing services and home health aide services) the physician must document that a face-to-face encounter related to the primary reason the patient needs home health services took place no more than 90 days before or 30 days after the start of services. If initially ordering medical supplies, equipment, or appliances, the physician or an authorized non-physician provider (NPP) must document that the face-to-face encounter occurred no more than six months prior to the start of services. In both cases, the physician or certain authorized NPPs must be the one performing the face-to-face encounter.

The final rule is effective on July 1. However, CMS recognizes that state governments and physicians may need time to deal with the operational and financial effects of the changes. Accordingly, CMS is delaying compliance with this rule for up to one year (July 1, 2017) if a state’s legislature has met in that year or two years (July 1, 2018) if not. A CMS fact sheet offers additional information.

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

Friday, January 29, 2016

Survey: EHR adoption continues to increase, information sharing limited

The percentage of office-based physicians using federally certified electronic health record (EHR) systems continued to climb in 2014 although the number sharing patient information with third parties was limited, according to new federal data.

The Centers for Disease Control and Prevention, referencing the National Electronic Health Records Survey, says 74.1 percent of physicians in 2014 reported having a certified EHR, up from 67.5 percent in 2013. Primary care physicians, including family physicians, were more likely to have a certified EHR (78.6 percent) compared with non-primary care specialists (70.3 percent).

Researchers theorized that incentives provided through the Centers for Medicare & Medicaid Services’ meaningful use program helped encourage physicians to adopt certified EHRs.

One of the goals of persuading physicians to adopt EHRs is so they can share medical history, lab results, medication, and other patient information with other physicians and hospitals as the patient moves between health care providers.

The survey showed that 32.5 percent of physicians with certified EHRs were electronically sharing patient information with third-party ambulatory physicians or nonaffiliated hospitals. By comparison, only 16.8 percent of physicians without a certified EHR were sharing information with those third-parties.

The numbers were even smaller for electronically sharing patient information with other types of health care providers. The survey found that 15.2 percent of those with certified EHRs said they shared information with home health providers, 13.6 percent shared with long-term care providers, and 14 percent shared with behavioral health providers.

Wednesday, January 27, 2016

CMS sets submission deadlines for 2015 PQRS data

Have you submitted your 2015 Physician Quality Reporting System (PQRS) data yet? If not, you still have time to do so without incurring a penalty in 2017.

The Centers for Medicare & Medicaid Services (CMS) has announced the 2015 PQRS data submission deadlines, which vary depending on how you plan to submit your data:

•    Electronic Health Record Direct or Data Submission Vendor (quality reporting data architecture I/III) – Feb. 29
•    Qualified Clinical Data Registries (quality reporting data architecture III) – Feb. 29
•    Group Practice Reporting Option Web Interface – March 11
•    Qualified Registries (such as the PQRS Wizard) – March 31
•    Qualified Clinical Data Registries XML – March 31

All submission deadlines end at 8 p.m. (EST) on the date listed. You will need an Enterprise Identity Management (EIDM) account with the “Submitter Role” for these PQRS data submission methods. Please see the EIDM System Toolkit for additional information.

Also, be aware that the Physician and Other Health Care Professionals Quality Reporting Portal may be unavailable while the system is undergoing maintenance. Maintenance is currently scheduled for the following time frames (all times are EST):

•    Feb. 26 at 8 p.m. – Feb. 29 at 6 a.m.  
•    March 11 at 8 p.m. – March 14 at 6 a.m.  
•    March 16 at 8 p.m. – March 21 at 6 a.m.  

Eligible professionals who do not satisfactorily meet the 2015 PQRS requirements will be subject to a reduction in payment on all Medicare Part B Physician Fee Schedule services rendered in 2017.

For questions, please contact the QualityNet Help Desk at 1-866-288-8912 or via email at Qnetsupport@hcqis.org from 8 a.m. – 8 p.m. (CST). Complete information about PQRS is available on the CMS web site.  

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

Tuesday, January 26, 2016

New rules available for requesting MU hardship exceptions

Congress has provided additional details for physicians wanting to claim a hardship exception from the Medicare Electronic Health Record (EHR) Incentive Program, also known as “meaningful use” (MU). In December, President Obama signed into law the Patient Access and Medicare Protection Act (PAMPA), which gave Congress the authority to streamline the exception process.

The updated process reduces the amount of information required to apply for an exception. For example, multiple providers can now use the same exception application. Also, the Centers for Medicare & Medicaid Services (CMS) can review applications based on “categories” rather than on a case-by-case basis. These categories include: insufficient Internet connectivity, extreme and uncontrollable circumstances, lack of control over Certified EHR Technology (CEHRT) availability, and lack of face-to-face patient interaction.

Physicians who did not successfully meet the MU requirements for the 2015 reporting year may apply for a hardship exception. If granted, the exception would protect the physician from the negative payment adjustment that would have been applied in 2017. An exception is effective for one year – physicians must reapply each year they wish to be exempted. A new eligible professional (EP) who began submitting Medicare claims in 2015 does not need to apply for an exception.

If you want to use the streamlined exception process, you need to submit your application by March 15. CMS will notify applicants of its determinations by email. All decisions are final and cannot be appealed. CMS encourages the use of the electronic application to avoid potential processing delays.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Thursday, January 21, 2016

Open Payments system gets an update – and a time out

The Centers for Medicare & Medicaid Services (CMS) has updated its Open Payments database, which tracks payments and "transfers of value" to physicians and teaching hospitals from pharmaceutical and medical device manufacturers or group purchasing organizations.

CMS typically updates the information at least once a year to address disputed payments and other corrections made since the data was first reported. The database now covers $9.9 billion in financial information submitted during the program's initial two years.

The Open Payments Data website now has added functionality, allowing visitors to search by name for payments tied to a doctor and view summaries of trends found in the data.

The Open Payments system itself is undergoing maintenance Jan. 21-26. Physicians won’t be able to access the system during this time, but the public website will still be available.

Visit CMS' Open Payments program website for more information and the Resources website if you still haven’t registered. Registration is required before physicians can review payments or transfers of value tied to their name and file a dispute or correction.

Thursday, January 14, 2016

Surveyed physicans say burnout is increasing

A new study indicates the ongoing focus on physician burnout is not unwarranted. The number of physicians unhappy in their practices is on the upswing.

Medscape’s Lifestyle Report 2016 found that the burnout rate for physicians in 25 specialties surveyed went up from past studies. Fifty percent or more of respondents from a dozen specialties reported a lack of personal accomplishment, cynicism about their work, and a general lack of joy coming into the office.

Among those were family physicians, 54 percent of whom said they were burned out.

On a scale of one to seven, with seven being the worst, family physicians rated their feelings of burnout at 4.37. This was the seventh-highest severity rating, tied with cardiologists. Critical care physicians reported a slightly higher rating at 4.74. Psychiatrists reported the lowest rating at 3.85.

Female physicians again reported a higher prevalence of burnout (55 percent) than their male counterparts (46 percent), although both genders have seen a steady increase since 2013 (45 percent and 37 percent, respectively).

Respondents identified increased bureaucratic tasks as the leading cause of their burnout, although working too many hours, increasing use of computers, and inadequate income also scored highly.

The survey, which polled almost 16,000 physicians, also asked about potential biases toward specific groups of patients and how likely those biases affected the treatment they provided. It found that overall 40 percent of physicians reported some level of bias, with family physicians reporting the fourth-highest level at 47 percent. The highest was among emergency medicine physicians (62 percent), while the lowest was among pathologists (10 percent), a specialty that rarely deals with patients directly.

In terms of whether bias affected patient treatment, 11 percent of family physicians said it did, the same rate as orthopedists, psychiatrists, and rheumatologists. The highest rates were 14 percent of emergency medicine physicians and 12 percent of plastic surgeons. The survey noted that of those who reported that their biases affected how they treated their patients, 29 percent said the effect was negative, 25 percent said it was positive (e.g., overcompensation and special treatment), and 24 percent said it was a mix of the two.

The survey also suggested there may be a relationship between burnout, which can cause depersonalization, and bias. Forty-three percent of physicians who reported burnout also reported bias, whereas 36 percent of physicians who did not report burnout reported bias.

Tuesday, January 5, 2016

CMS to require prior authorization for certain durable medical equipment

Starting next month, the Centers for Medicare & Medicaid Services (CMS) will begin requiring prior authorization for certain durable medical equipment, prosthetics, orthotics, and supplies.

The move, effective Feb. 29, follows several years of efforts by CMS to reduce fraud and overuse of these items, also known as DMEPOS.

Most recently, CMS implemented the DMEPOS Competitive Bidding Program and increased screening of suppliers, as authorized by the Affordable Care Act. In addition, CMS started a prior authorization demonstration program for power mobility devices, eventually expanding the trial from seven to 19 states.

The new process goes well beyond power mobility devices. It creates a “master list” of 135 DMEPOS items, a subset of which will be subject to prior authorization. CMS will publish this “required prior authorization list” 60 days before implementation.

If prior authorization is required for an item, the requester (usually the DMEPOS supplier) must provide CMS evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. This must be done before the item is provided to the Medicare recipient or a claim is filed for processing. While the supplier will typically provide this information, prescribing or ordering physicians should not be surprised if the supplier asks their office for assistance.

After CMS receives the Medicare documentation, the agency or its review contractors will conduct a medical review and decide whether to provisionally affirm the request. Medicare will pay claims filed with a provisional affirmation if other requirements are met. Claims with a non-affirmation or no decision will be rejected, although the agency will allow unlimited resubmissions of prior authorization requests.

Medicare says it or its review contractors will try to process prior authorization requests within 10 business days and process resubmitted requests within 20 business days. Expedited review will be available in certain circumstances, such as instances where waiting the normal time frame for prior authorization could seriously endanger the life or health of the patient.

CMS will also communicate specific prior authorization guidance in the future.

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

Monday, December 21, 2015

Congress passes legislation to provide meaningful use relief

Physicians who face potential Medicare payment cuts in 2017 because they can't meet new requirements for the meaningful use program in 2015 may soon get a reprieve.

Congress has passed legislation that requires the Centers for Medicare & Medicaid Services (CMS) to grant a hardship exemption from those penalties to any physician who requests one by March 15. The bill now goes to President Obama for his signature.

CMS released modifications to the meaningful use program in October, including new rules for Stage 2. For 2015, physicians may attest to the program by reporting any consecutive 90 days during the year.

Previously, CMS could provide hardship exemptions on a "case by case" basis. But the legislation's supporters, as well as several medical associations, said the late release of the Stage 2 changes means many physicians do not have enough time to meet the regulations and should be granted an automatic exemption. Failing to achieve meaningful use in 2015 can lead to a reduction in Medicare payments in 2017.

UPDATE: President Obama signed the bill into law on Dec. 28.

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