Medicare keeping vigilant on observation services
If you or your practice provides observation care at a local hospital to Medicare patients, the Centers for Medicare & Medicaid Services (CMS) is issuing a gentle reminder to pay attention to your documentation for those services – if you don’t want to face a refund request.
In the latest issue of CMS’s Medicare Quarterly Provider Compliance Newsletter, the agency indicates it is keeping a close eye on physician billing for hospital observation services. In the article, “Comprehensive Error Rate Testing (CERT): Observation Services,” CMS notes that evaluation and management (E/M) services, such as observation services, remain a leading cause of improper Medicare payments. CMS also notes that most improper payments were due to insufficient documentation, such as:
• No order for observation services
• No progress notes
• No physician’s signature on a progress note
As an example, CMS describes the case of a physician who billed Medicare for CPT 99217 (“Observation care discharge”) for a date of service in April 2013. However, the submitted documentation was missing signed and dated physician’s orders for observation services and was also missing a signed and dated progress note to support a face-to-face encounter on the date of service. The physician was unable to produce any documentation to support that he or another member of his group had seen the patient on the date of discharge from observation. Subsequently, the Medicare administrative contractor recovered the payment.
The article also reminds physicians that even when documentation is present, it must support the level of E/M observation service claimed. Failure to document the level of service claimed also constitutes a potential overpayment as far as Medicare is concerned.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
CMS provides details on Comprehensive Primary Care Plus
Like an auto company touting the latest model or a certain soda manufacturer unveiling its “new” version of an old “classic,” the Centers for Medicare & Medicaid Services (CMS) has revealed its latest effort to transform and improve how primary care is delivered and paid for in the United States. CMS will implement the Comprehensive Primary Care Plus (CPC+) model in up to 20 regions of the country, accommodating up to 5,000 practices and more than 20,000 physicians and other clinicians. It would also seek to encompass up to 25 million patients.
Building on the Comprehensive Primary Care initiative launched in late 2012, which is already being dubbed “CPC Classic,” the five-year CPC+ model will offer primary care practices two tracks for participation. Both tracks will require practices to:
• Support patients with serious or chronic diseases to achieve their health goals
• Give patients 24-hour access to care and health information
• Deliver preventive care
• Engage patients and their families in their own care
• Work together with hospitals and other clinicians, including specialists, to provide better coordinated care
Practices in Track 2 will also be expected to provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.
Physicians participating in CPC+ will receive monthly care management fees for eligible beneficiaries in their practice. Physicians in Track 1 will be paid depending on where each patient falls across four risk tiers, with an average of $15 per beneficiary per month. In Track 2, physicians will be paid according to five risk tiers, with an average of $28 per beneficiary per month, including $100 per month for the most complex patients. Practices can use these fees for increased staffing and training necessary to meet the model’s patient care requirements.
In addition to the care management fees, Track 1 physicians will continue to receive their normal Medicare fee-for-service payments. Physicians in Track 2 will receive a new hybrid of fee-for-service payments and a “Comprehensive Primary Care Payment,” which will include a percentage of the expected Medicare reimbursement for Evaluation & Management (E/M) claims upfront. Reimbursement for the E/M claims themselves will be reduced.
In addition to these payments, CMS will award practices incentives based on performance.
Like CPC Classic, Medicare will partner under the CPC+ model with commercial and state health insurance plans. CMS will accept proposals from payers wanting to partner in CPC+ between April 15 through June 1, selecting regions of the country that reflect sufficient interest from multiple payers. Practices in the selected regions can apply to participate from July 15 through Sept. 1.
CMS is offering additional information on CPC+ through a press release, a fact sheet, and frequently asked questions.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Open Payments review and dispute period ends May 15
Physicians and teaching hospitals have until May 15 to review financial information reported about them under the “Open Payments” system and dispute information they believe is incorrect before the information is released to the public on June 30.
The Centers for Medicare & Medicaid Services (CMS) annually asks pharmaceutical and medical device manufacturers and group purchasing organizations to report all payments or other transfers of value they made to physicians and teaching hospitals during the previous year. The June 30 release includes information for 2015, along with updates to the databases for 2013 and 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. Go to the CMS Enterprise Portal, log in using your user ID and password, and navigate to the Open Payments system home page. If you haven’t accessed your account in the last 60 days, you will need to answer some challenge questions and then reset your password. If you haven’t visited in more than 180 days, you’ll have to contact firstname.lastname@example.org to reinstate your account.
CMS releases 2015 mid-year Quality and Resource Use Reports
The Centers for Medicare & Medicaid Services (CMS) has released the mid-year Quality and Resource Use Reports (QRURs) for 2015. These reports are released annually and serve as a tool for physicians to review their performance on a subset of measures that will be used to calculate the 2017 Value-Based Payment Modifier (VBPM).
The mid-year QRURs are for informational purposes only and cover the performance period between July 1, 2014, and June 30, 2015. This performance period differs from the actual performance period that will be used to calculate the 2017 VBPM. The reports contain data on six cost measures and three claims-based quality outcome measures.
While the performance information included on the mid-year QRUR may differ from the 2015 QRUR, which comes out in the fall, the report still offers physicians a good opportunity to review their performance and implement quality improvement activities for the upcoming year. A physician’s performance in 2016 will be used to calculate his or her 2018 VBPM.
-- Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians
Groups can now register for the 2018 PQRS
Physician practices wanting to use the Group Practice Reporting Option (GPRO) to participate in the 2018 Physician Quality Reporting System (PQRS) have until June 30 to register. If not, all providers within the group must report to PQRS as individuals or face a Medicare pay penalty in 2018.
The Centers for Medicare & Medicaid Services (CMS) defines a “group” as a single Tax Identification Number (TIN) with two or more individual providers with National Provider Identifiers (NPIs) who have reassigned billing rights to the TIN. Groups can register using an Enterprise Identity Management (EIDM) account. CMS encourages users to create or modify existing EIDM accounts now to avoid delays. If you are unsure if someone in your group is already enrolled with the EIDM system, contact the QualityNet Help Desk. You will need the group’s TIN and name.
During registration, you will select your reporting method. Your choices are:
• Qualified PQRS Registry
• Electronic Health Record (EHR)
• Qualified Clinical Data Registry (QCDR)
• Web Interface (for groups with more than 25 providers)
Physicians wanting to report using the EHR or QCDR methods will need to be sure that their vendors meet the requirements for group reporting. Additionally, groups with between two and 99 eligible professionals (EPs) will need to decide if they want to supplement their reporting with the Consumer Assessment of Health Care Providers and Systems (CAHPS) for the PQRS survey. CAHPS is required for groups with 100 or more EPs.
All groups and solo physicians will be subject to the 2018 Value Modifier. Participation in the PQRS program will help you avoid the automatic downward payment adjustment for failure to satisfactorily report.
--Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians
Compensation for family physicians rises in new survey
Family physicians saw their average overall compensation increase last year, and they felt slightly less anxious about their pay and their profession, according to a new report.
The Medscape Physician Compensation Report 2016, released April 1, reported that family physicians made an average of $207,000 in total compensation in 2015, up 6 percent from the previous year. Most specialties saw gains in annual compensation, with the highest-paid physicians being orthopedists with an average of $443,000. The lowest-paid specialty was pediatrics with an average of $204,000.
In addition to receiving higher pay, 52 percent of all physicians (and 52 percent of family physicians) said they believed their compensation was fair. By comparison, half of all physicians and 48 percent of family physicians felt they were fairly compensated in 2014. Dermatologists (66 percent) felt the most comfort with their compensation, while urologists (42 percent) were the least satisfied. Among family physicians, 73 percent said they would still choose medicine as a career if they had to do it all over again, which is up from 69 percent five years ago. The percentage of family physicians who would stick with the specialty, however, has fallen from 44 percent in 2011 to 29 percent now.
The trend of physicians choosing to work for hospitals and other large health care groups appeared to remain steady with 35 percent of men and 23 percent of women sticking with private practice, virtually the same percentages as a year ago.
Male and female compensation continued to have a disparity, but it is shrinking. Male family physicians made an average of $220,000 versus $183,000 for female family physicians, a difference of 20 percent. The difference was 28 percent in 2011. Also, survey results showed that female physicians faced a similarly sized pay gap regardless of whether they were employed or self-employed.
Despite the continued focus on “direct primary,” “concierge,” or “direct pay” care models, those types of practices remain very much in the minority. Only 10 percent of family physicians reported being in a concierge or cash-only practice, the same amounts as in 2014. The researchers said it appeared private practice physicians looking to get away from the regulatory and financial headaches of traditional practice are more likely to go into employed positions rather than go the direct-pay route.
The survey also said 39 percent of family physicians were in an accountable care organization (ACO) and 7 percent planned to join one in the coming year. By comparison, 35 percent belonged to one in 2014 and 8 percent planned to join one.
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