Changes coming to Medicare payments for durable medical equipment

If you prescribe durable medical equipment (DME) for your Medicare patients, you should be aware that, effective July 1, Medicare will expand its competitive bidding program for DME, prosthetics, orthotics, and other supplies. The expansion may affect where your patients can fill their prescriptions and how much they and Medicare end up paying for the DME.

The Centers for Medicare & Medicaid Services (CMS) introduced its competitive bidding program in nine areas of the country in 2011. Based on the program's success in those areas, CMS is extending it to 91 new areas across the country. CMS will also implement a national mail-order program for diabetic testing supplies on July 1.

The program affects Medicare payments for wheelchairs, oxygen, mail-order diabetic supplies, and more. Historically, Medicare based its payment for most of these items on historical charges, adjusted for inflation over time. However, many studies have shown that the prices Medicare has paid for certain medical equipment and supplies are excessive – sometimes three or four times retail prices and the amounts paid by commercial insurers.

Under the competitive bidding program, suppliers submit bids for certain medical equipment and supplies that must be lower than what Medicare pays for these items currently. Medicare then uses the bids to set the amount it will pay for those items and chooses the qualified, accredited companies with winning bids as Medicare contract suppliers. The lower Medicare payment amounts also lower a Medicare beneficiary’s co-payment.

The competitive bidding is part of CMS's efforts to fight fraud and waste in the Medicare program. Media reports have noted that, from 2009 to 2012, Medicare paid $43 billion for DME, more than 60 percent of which may have been improper. Similarly, CMS has introduced a pilot program that requires approval before Medicare will pay for power wheelchairs and scooters for beneficiaries in seven states with high rates of fraud and errors: California, Illinois, Michigan, New York, North Carolina, Florida, and Texas.

You and your patients can find a list of Medicare contract suppliers in your area by visiting Medicare's supplier directory tool or by calling 1-800-MEDICARE. For additional information, visit the Medicare DME Competitive Bidding Program's website, which includes all of the products and items that are covered under the program.

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

Posted at 04:49PM May 14, 2013 by David Twiddy, Associate Editor  |  Comments[0]

A limited time opportunity on eRx penalties

Time is running out for physicians to avoid having their Medicare Part B fees cut next year under a federal initiative that encourages electronic prescribing.

The Centers for Medicare & Medicaid Services (CMS) has given practices until June 30, 2013, to show that they have met e-prescribing (eRx) requirements during the first six months of this year (or during the 12-month eRx reporting period of Jan. 1, 2012-Dec. 31, 2012) or to request a hardship exemption from the requirements to avoid the 2014 penalty. (CMS calls it a "payment adjustment.")

Practices can also avoid the 2014 penalty if they do one of the following by June 30, 2013:

•    Register to participate in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program and adopt certified EHR technology; or

•    Attest achievement of meaningful use under the EHR Incentive Program during either the 12-month eRx reporting period (Jan. 1, 2012-Dec. 31, 2012) or the six-month eRx reporting period (Jan. 1, 2013-June 30, 2013).

If you are currently subject to the eRx payment adjustment or have been in the past, you are not alone. CMS reports that 135,931 eligible professionals were subject to the 2012 eRx payment adjustment because they did not qualify for an exemption, meet exclusion criteria for the adjustment, or comply with eRx reporting requirements in the first half of 2011.

The payment adjustment in 2014 will be 2 percent, which means if you are subject to the adjustment, you will only receive 98 percent of your Medicare Part B physician fee schedule amount for covered professional services, assuming you are not subject to any other payment adjustments under Medicare.

On March 1, CMS re-opened the Quality Reporting Communication Support Page to allow individual eligible professionals and group practices the opportunity to request a significant hardship exemption for the 2014 eRx payment adjustment. As noted, hardship exemption requests will be accepted through June 30, 2013. After that, you're out of luck. Also, please note this applies only to hardship exemption requests for the 2014 eRx payment adjustment. The reporting period to avoid the 2013 eRx payment adjustment, or to submit hardship exemption requests, has ended.

The following resources are available to assist individual eligible professionals and group practices in submitting their request for a hardship exemption:

• Quality Reporting Communication Support Page User Guide

• Tips for Using the Quality Reporting Communication Support Page

For additional information on the 2014 eRx payment adjustment, including who is subject to the payment adjustment and how to avoid it, please review the 2014 eRx Payment Adjustment Fact Sheet.

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

Posted at 11:50AM Apr 23, 2013 by David Twiddy, Associate Editor  |  Comments[0]

CMS refuses to halt ICD-10-CM implementation

The Centers for Medicare & Medicaid Services (CMS) has denied a request from more than 80 state and national physician organizations, including the American Academy of Family Physicians (AAFP), to halt implementation of ICD-10-CM.

The Dec. 20, 2012, letter to CMS Acting Administrator Marilyn Tavenner requesting the delay argued that the new set of outpatient diagnosis coding would create additional, unnecessary burdens for America's physicians at a time when many are overwhelmed with other health care system demands and changes.

On Feb. 6, 2013, Tavenner declined the request and said that CMS will move forward with implementing ICD-10 on Oct. 1, 2014. She noted that this already represented a year’s extension beyond the original implementation date of Oct. 1, 2013. Tavenner also said that halting implementation at this point "would be costly, burdensome, and would eliminate the impending benefits" of the investments that many in the industry have already made with respect to implementation.

So, for now, ICD-10 proponents have carried the day, and everyone needs to look for strategies to ease implementation. If you have not already developed an implementation plan, here are some resources to help you.

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

Posted at 02:47PM Feb 20, 2013 by David Twiddy, Associate Editor  |  Comments[1]

Decoding the new transitional care management rules

Ever since their introduction at the beginning of the year, the new transitional care management (TCM) codes have caused confusion.

The Getting Paid blog described the new codes when they were first announced last fall. But the questions have continued, and the codes are getting additional attention after the CPT Editorial Panel clarified in January that transitional care management involving new patients, and not just ones that a physician has seen within the previous 12 months, could be billed using the TCM codes.

Here are some of the more common questions:

Q. When should I bill for TCM?
A. You should submit your bill on the 30th day after discharge. TCM covers 30 days of management services with one evaluation service bundled into the code. The date of service on the claim would be the 30th day after the discharge.

Q. What happens if the patient is re-admitted before the 30 days are up?
A. The face-to-face visit would become the appropriate level evaluation and management code for the service that was rendered. You would restart your 30 days of service on the TCM once the patient was discharged.

Q. Does a discharge visit count as the post discharge contact?
A. No, a discharge visit does not count. The initial contact must be made after the patient leaves the hospital. This is to make sure that the patient has the support necessary until they have their face-to-face visit. The initial contact can be phone, e-mail, text, or face-to-face. It can involve the patient and/or the patient's caregiver.

Q. If the patient needs an unrelated evaluation and management (E/M) visit during the 30 days can I bill for this?
A. Yes, although there are some restrictions on what you can bill, such as anticoagulation management and home health care certification.

We’ve yet to hear how these codes are getting paid since the earliest billing date would have been Jan. 30, 2013. We are also waiting on the Centers for Medicare & Medicaid Services (CMS) to release guidelines on the codes, which we expect to receive by the end of February.

AAFP has created a form to help you document the requirements of TCM visits and made available for download a list of frequently asked questions. TCM was also discussed as part of an AAFP/TransforMED webinar, “What’s new in Medicare and Medicaid payment in 2013,” which is archived on TransforMED's Delta Exchange site and accessible to AAFP members upon login.  

–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians

Posted at 05:10PM Feb 12, 2013 by David Twiddy, Associate Editor  |  Comments[10]

Time running out for PQRS and eRx incentives

It's not too late to participate in a pair of federal incentive programs targeting clinical quality and computerized prescriptions. But you need to move fast.

The Centers for Medicare and Medicaid Services (CMS) this week hosted a national call to discuss how physicians and other eligible health care professionals can submit 2012 program year data for the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program.

In case you missed it, below are some of the highlights.

For individual eligible professionals, you still have time to participate in the 2012 PQRS if you report your information either through a qualified registry or through a qualified electronic health record (EHR). The EHR option can communicate either directly or through a data submission vendor.

Registry vendors can submit data between Feb. 1 and March 31. EHR users can already submit their data, but they only have until Feb. 28. No submissions after the end dates will be allowed.

You may potentially qualify to receive a full-year incentive payment. But even if you don't, it's good experience in reporting PQRS measures before tackling 2013, which is the reporting period CMS will use in determining PQRS penalties in 2015.

The same options and dates apply with respect to the eRx Incentive Program. As with the PQRS, you may potentially qualify to receive a full-year incentive payment, and you may potentially qualify to avoid the 2014 eRx penalty. However, to avoid a penalty this year, you had to have complied with the program by June 30, 2012.

For more information on the programs, you can find the presentation from the national call online.

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

Posted at 11:09AM Jan 23, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Avoiding Medicare cliff still has initial consequences for payment

With the Medicare payment cliff averted for now, Medicare and its contractors are beginning to implement payments for 2013 services. Here is what you can expect, based on information provided by the Centers for Medicare and Medicaid Services (CMS).

First, CMS is revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law's requirements as well as technical corrections identified since publication of the final rule on the 2013 MPFS in November 2012. Officially, the 2013 conversion factor is $34.0230.

Second, to allow sufficient time to develop, test, and implement the revised MPFS, Medicare contractors were able to hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through Jan. 15). CMS expected those claims to be released into processing no later than Jan. 16. The claim hold should have minimal impact on your cash flow, however, because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt anyway. Claims with dates of service prior to Jan. 1, 2013, are unaffected.

Medicare contractors will be posting the correct MPFS payment rates on their websites no later than Jan. 23. If you have downloaded or will be downloading the fee schedule from your local Medicare contractor's web site, double-check to ensure that it reflects the correct rates, based on the recent change in the law.

Finally, the 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their Medicare participation status by Dec. 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through Feb. 15, 2013. Therefore, you have until Feb. 15, 2013, to postmark any participation changes (both elections and withdrawals) that you want to make. The effective date for any participation status changes during the extension remains Jan. 1, 2013, and will be binding for the rest of the year.

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

Posted at 01:35PM Jan 17, 2013 by David Twiddy, Associate Editor  |  Comments[0]

'Tis the season...influenza season, that is

The Centers for Medicare & Medicaid Services (CMS) released its annual update to influenza vaccine payments in early October, effective for dates of service on or after Aug. 1, 2012. Here’s an overview of what your Medicare contractor should be paying you.

CMS has payment allowances for several CPT and HCPCS codes for seasonal influenza virus vaccines. These allowances are typically based on 95 percent of the average wholesale price. However, when physicians furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center, payment is based on reasonable cost and other allowances may apply.

The following table shows the payment allowances (based on 95 percent of the average wholesale price) for the most common codes:

Note that CMS has permitted payment allowances for some influenza vaccines to be set by the local claims processing contractor. Specifically, local contractors set the payment amounts for Q2034, Influenza virus vaccine, split virus, for intramuscular use (Agriflu), and Q2039, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Medicare payment for some other influenza vaccine codes is available only after the local claims processing contractor determines that the vaccine in question is medically reasonable and necessary for the beneficiary. These include:

•    90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID); Part B allowance of $18.981,
•    90660 – Influenza virus vaccine, live, for intranasal use (FluMist); Part B allowance of $23.456,
•    90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose); Part B allowance of $30.923.

The additional scrutiny that Medicare is giving these codes is probably due in part to their costs compared with the traditional injectable influenza vaccine. Beyond that, code 90654 is a new code reflecting a new route of administration (i.e., intradermal), and the “enhanced immunogenicity” represented by code 90662 is probably not universally needed, leading Medicare to make sure that those who receive it do so appropriately. Finally, an article published by the Medicare contractor in Florida suggests that 90660 is only indicated for healthy individuals between 2 to 49 years of age, again leading Medicare to ensure that those who receive it do so appropriately.

In closing, it is worth pointing out that the allowances above are effective with dates of service on or after Aug. 1, 2012; however, Medicare contractors have until Dec. 28, 2012, to implement these allowances, so it is possible that some of your influenza vaccine claims may not be paid at the correct rate in the interim. Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention, so if you submitted a claim that is not paid at the correct allowance, you need to bring that claim to the contractor’s attention for adjustment.

For more information, check out the MLN Matters article (MM8047) "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season.”

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

Posted at 11:30AM Nov 02, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

Recovery audit contractors get a new fishing license

In a previous blog post, I discussed the Centers for Medicare & Medicaid Services’ (CMS) decision to allow one of its recovery audit contractors (RAC), Conolly, to begin auditing claims for evaluation and management codes, specifically code 99215. Earlier this month, the U. S. Court of Appeals for the 9th Circuit gave RACs and other Medicare contractors even more discretion in this regard. Specifically, in Palomar v. Sebelius, D.C. No. 3:09-cv-00605-BEN-NLS (Sept. 11, 2012), the court upheld that a decision by a RAC to reopen a Medicare claim for complex review was not reviewable.

The Palomar case involved a RAC's determination that services provided to a Medicare beneficiary were not reasonable and necessary. The claim in question was more than one year old and could only be reopened for "good cause" under Medicare regulations. All of the reviewers that examined the case agreed with the RAC's determination regarding medical necessity. However, the administrative law judge who reviewed the RAC determination concluded that there was not good cause to reopen the claim and reversed the RAC decision.

On appeal, the Medicare Appeals Council (MAC) reversed the administrative law judge decision. The council ruled that the Medicare regulation at 42 C.F.R. § 405.980(a)(5) makes a Medicare contractor's decision to reopen a claim unreviewable. Both the U.S. District Court and the U.S. Court of Appeals for the 9th Circuit affirmed this opinion. The courts held that the regulation expressly forecloses jurisdiction to review the reopening decision and that providers may only appeal the substance of a contractor's overpayment determination (e.g. whether or not the services were reasonable and necessary).

The Secretary for the U.S. Department of Health & Human Services argued that the review of contractors' compliance with the regulations is solely a matter for CMS's performance evaluations of the contractors. That leaves physicians at the mercy of CMS’s ability to manage its contractors.

Additionally, because the RACs get a cut of every overpayment that they find, they have incentive to reopen claims whether or not "good cause" exists under the Medicare regulations. This is especially true because most determinations finding an absence of medical necessity are based on a lack of documentation, and because it will be harder to find documentation and testimony to support older claims.

The "good cause" requirement was an important source of protection against contractor fishing expeditions. Unfortunately, the Palomar decision just gave RACs and other Medicare auditors a virtually unlimited fishing license going forward.

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

Posted at 07:43AM Sep 27, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

Coming attractions: Medicare physician fee schedule

One of my favorite things about going to the movies is watching the "trailers" or "previews" that precede the main feature. I enjoy the glimpses of things to come and the anticipation that they foster.

Last week, the Centers for Medicare & Medicaid Services (CMS) offered a preview of the 2013 Medicare physician fee schedule in the form of a notice of proposed rule making (NPRM) published in the Federal Register. You can download a copy of the NPRM and view related links on the CMS website. The AAFP has provided a summary of the 341-page document.

As usual, the proposed rule for next year's fee schedule is full of interesting payment policy proposals. From a family medicine perspective, the most interesting one is a proposal to create and pay for a code that community physicians may report when they manage the care of a patient who is transitioning from a facility to an ambulatory, outpatient setting (e.g., from the hospital back to the community). CMS recognizes that a lot of expensive re-admissions could be prevented if transitions of care were better managed, and CMS appears willing to pay community physicians, including family physicians, for doing just that. CMS estimates that this proposal alone will increase Medicare allowed charges to family physicians by 5 percent in 2013.

Of course, not everything related to the Medicare physician fee schedule is good news. CMS separately estimates that, under current law, the physician fee schedule conversion factor will decrease 27 percent on Jan. 1, 2013, unless Congress and the President again intervene in the process.

CMS is accepting comments on its proposed rule until Sep. 4, 2012, so if you want to provide any feedback that may help shape the final product, you will need to submit it between now and then. Options for how to submit comments are included in an early section of the NPRM.

CMS plans to publish the final rule on or about Nov. 1, 2012, with implementation effective Jan. 1, 2013. Think of it as "show time" for the 2013 Medicare physician fee schedule. Here's hoping that the final product is more of an uplifting picture than any sort of comedy or horror show.

Posted at 11:13AM Aug 08, 2012 by Kent Moore  |  Comments[0]

Screen before you counsel for alcohol misuse

The Centers for Medicare & Medicaid Services recently issued further instructions for contractors processing claims for the preventive medicine benefit for alcohol misuse counseling, which was added last fall. If a claim is submitted for code G0443 (brief face-to-face behavioral counseling for alcohol misuse, 15 minutes) when there are no claims for code G0442 (annual alcohol misuse screening, 15 minutes) in the prior 12 months, the contractor will deny the claim for G0443. The article also reminds contractors and physicians that Medicare will only pay for up to four G0443 services within a 12-month period. Claims for G0443 that exceed that four session limit in a 12-month period will be rejected.

Some other reminders about these services:

• Medicare will allow payment for both G0442 and G0443 on the same date (except in rural health clinics and federally qualified health clinics), but will not pay for more than one G0443 service on the same date.
•  Code G0442 is an annual benefit so at least 11 months must pass between services.
• Both the screening and counseling services have time elements of 15 minutes, so time should be documented in addition to screening or counseling notes.
• Counseling for alcohol misuse must be based on the Five As (Assess, Advise, Agree, Assist, and Arrange), so be sure your documentation reflects this.
• The alcohol screening and counseling services are payable with another visit on the same day (e.g., office visit for other problems), except for the Initial Preventive Physical Exam ("Welcome to Medicare" physical).
• These services are not subject to deductible or co-insurance.
• National average fee schedule amounts for these services are $17.36 for G0442 and $25.19 for G0443.

Posted at 10:40AM May 21, 2012 by Cindy Hughes  |  Comments[2]

Comprehensive Primary Care Initiative: Coming soon to a market near you?

The Center for Medicare & Medicaid Innovation (CMMI) has identified the markets where it will test its Comprehensive Primary Care Initiative (CPCI), according to information posted yesterday on the CMMI website. CPCI, which was announced last fall, will test a payment model that offers physicians a monthly care management fee for each Medicare fee-for-service patient in their care as well as a share of any savings that the initiative generates. The following markets were chosen based on applications from payers:

• Arkansas,
• Colorado,
• New Jersey,
• New York (Capital District/Hudson Valley Region),
• Ohio (Cincinnati/Dayton region),
• Oklahoma (Greater Tulsa region),
• Oregon.

Approximately 75 practices in each market will be chosen to participate. CMMI will solicit applications from practices as soon as final agreements are signed with the participating payers, which include private health plans, state Medicaid agencies, and employers, as well as Medicare.

CPCI is a four-year initiative with a planned launch date this summer.  If it is shown to improve quality of care and lower costs, CMMI has the authority to roll out the initiative nationwide. Read more about the initiative in Family Practice Management.

Posted at 10:49AM Apr 12, 2012 by Leigh Ann Backer, Exec. Editor  |  Comments[0]

Additional Documentation Requests: Don't ignore them

Family physicians in the Medicare J5 MAC region states of KS, MO, NE, and IA providing inpatient care should be prepared to receive and promptly respond to letters from the WPS Medicare Medical Review Department. These will be related to prepayment review of claims for subsequent hospital visits submitted with code 99233. WPS notes that their Comprehensive Error Rate Testing (CERT) reviews of paid claims have shown a significant increase in errors on claims for these services by family physicians. If one of your claims is selected for review, WPS will send an Additional Documentation Request (ADR) for medical records for all dates of service billed with CPT code 99233.

Breathing a sigh of relief because you are not in one of the J5 MAC states? I can see that. No one wants their payments delayed and subjected to prepayment review and potential denial or down-coding. But if your Medicare CERT or one of the myriad other Medicare auditors isn’t looking at your inpatient hospital services, I would bet they are looking at some other evaluation and management (E/M) service that may have been inadequately documented or incorrectly coded. If post-payment review results in a high error rate, you too may find your payments delayed, reduced, or denied.

So what can you do to avoid problems?

First respond promptly and completely to all ADR letters. Many claims are denied and counted as errors due to lack of response to ADR's. See the information previously provided in this blog for details. 

Second, be sure that documentation submitted is clear, complete, appropriately signed, and dated. Did you and your partner provide E/M services on the same date and bill the services according to Medicare rules as one E/M service? Will both notes be sent? If not, your 99233 visit may be down-coded to 99231 or 99232. A records request checklist can help your staff submit all of the information necessary to support your charges.

Are you using 99233 only when the patient is unstable or has developed a significant complication or a significant new problem? If billing based on time, have you documented counseling and coordination of care for at least half of a visit (including hospital floor time) of 35 minutes or more?

Finally remember, code 99233 requires at least two of these three components:

• A detailed interval history – state progress or complications since last visit, if referring to previous history state date of previous history, chief complaint or reason for visit beyond “follow-up,” HPI (4 items or 3 conditions), ROS (2-9 systems), PFSH (none necessary);

• A detailed examination – Extended exam of problem system/areas plus others;

• Medical decision making of high complexity (2 of 3 elements, not risk alone) – established problem(s) worsening; new problems with or without further work-up; changes in treatment, nursing instructions, decisions for palliative care, tests and procedures ordered (note if urgent), tests reviewed and unexpected results, discussions with other physicians, risks of management and treatment.

It is complex and probably annoying but remember, it is necessary to show the work (talking, reviewing, thinking) that you did to support your charges. A 99233 service should not go unpaid due to lack of response to ADRs, unsigned records, or other documentation gaps.

Posted at 04:23PM Mar 30, 2012 by Cindy Hughes  |  Comments[2]

EHR incentives and PQRS can work together

I have written before about the Medicare Physician Quality Reporting System (PQRS) and the advantages of the registry-based or electronic health record (EHR)-based reporting options. Though the incentive payment for successful reporting in 2012 will be only .5% of your total allowed charges for covered Medicare Part B services provided during the reporting period, there are other reasons to report.

First, those of you who are participating in the Medicare EHR incentive program may be able to satisfy the core requirements for reporting clinical quality measures (CQMs) through Medicare's Physician Quality Reporting System – Electronic Health Record (EHR) Incentive Pilot. Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report the 44 CQMs to the Centers for Medicare & Medicaid Services (CMS) in two ways:

1. Using the Medicare and Medicaid EHR Incentive Programs’ web-based Registration and Attestation System, or

2. Participating in the Physician Quality Reporting System – Medicare EHR Incentive Pilot, which utilizes the 2012 Physician Quality Reporting System EHR Measure Specifications.

By submitting specific Physician Quality Reporting EHR Measures through the pilot, participants can focus on the same sample of beneficiaries for the Medicare EHR Incentive Program and for the Physician Quality Reporting System for the 2012 program year. Eligible professionals participating in the Physician Quality Reporting System – Medicare EHR Incentive Pilot are still required to report the other meaningful use objectives through the Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.

Second, beginning in 2013, failure to successfully report PQRS measures will result in an adjustment (penalty) of -1.5 percent on all Medicare payments in 2015.

Third, even those without a qualified EHR system can successfully participate in the PQRS program without the hassles of the claims-based reporting that has proven quite burdensome and unsuccessful for many practices. The registry-based option allows for successful reporting with selection of a measures group for which you will report on 30 Medicare patients using an online registry program such as the AAFP PQRIwizard.

You can find more information on the PQRS program and the EHR-based and registry-based reporting options on the CMS PQRS Alternative Reporting Mechanisms page. Don't give up the full amounts allowed under the Medicare Physician Fee Schedule.

Posted at 02:17PM Mar 08, 2012 by Cindy Hughes  |  Comments[0]

What the 2012 Medicare Physician Fee Schedule tells us about the future

The final rule for the 2012 Medicare Physician Fee Schedule went on display this week. Of course it includes the all-too-familiar fee cut (27.4 percent) – the result of the Centers for Medicare & Medicaid Services' (CMS) flawed formula for calculating physician payment that Congress has been patching annually since 2002 but which needs a permanent fix. This year's fee schedule is notable for another reason as well. The PDF file is 1,235 pages long, and that's without the appendices that will be included when the final rule is published in the Federal Register later this month. The fact that it requires so many pages to describe one year's changes to one part of one government program is mind-boggling, but the additional bulk is partly because this year the rule also provides a forecast for how CMS plans to carry out government mandates for the program over the next five to 10 years. It is not a crystal ball, but the rule leaves no doubt that Medicare payment to physicians will be changing and that today's initiatives and incentives are intended as the basis for tomorrow's payment.

Examples of this are especially clear in the portion of the rule that speaks about a value-based payment modifier, which will actually modify payments under the Medicare Physician Fee Schedule based on Medicare's record of the quality of care you provide to patients compared with the cost of that care. Where will Medicare get this data? Primarily from the quality measures reported for programs like the Physician Quality Reporting System and the EHR Incentive Program and from claims data for your patients. Physicians who are found to deliver high quality for the cost of care will be paid more than other physicians. The program is budget neutral, so one physician's gain is another physician's loss.

CMS is still working out the details, such as how to attribute patients to physicians, adjust for risk and complexity, and make the measurements meaningful for all specialties. What is clear from the rule is that the process is underway to put the value-based modifier in place by 2015 for some physicians (based on claims and quality reporting in 2013) and by 2017 for all physicians (probably based on claims and quality reporting in 2015).

 CMS has this to say in the final rule:

"We strongly encourage physicians to participate in the Physician Quality Reporting System program and the EHR Incentive Program sooner rather than later and to choose to report quality of care measures that best reflect their practice and patient population. Although we have not yet proposed the value modifier methodology, our primary interest at this point is to increase the quality of care for Medicare beneficiaries. We note that we also plan to propose a value modifier in rule making during 2012, prior to the initial performance period. Thus, we believe it is reasonable to encourage physicians to report appropriate quality measures well in advance and irrespective of the exact value modifier methodology at this time."

The complexity and unknowns of this value based payment system are daunting.  However, this could be a good thing if physicians who know their patients and provide comprehensive, coordinated care are rewarded for their work. Sounds like family medicine to me.

Posted at 11:06AM Nov 11, 2011 by Cindy Hughes  |  Comments[1]

Your Medicare participation options

A couple of recent news items have me asking again a question previously asked on this blog in October of 2010. "Why would any physician in his [or her] right mind want to participate in a system such as this [Medicare]?"

First, the ever-voluminous proposed rule for the Medicare Physician Fee Schedule has been published and is now open to comment. Looming above all the program changes and some potential additional work that is proposed is the ever-constant threat of a pay cut due to the sustainable growth rate (SGR). If Congress, also charged with reducing a massive budget deficit, does not act to either fix the SGR or again delay the related decrease in payments, the Medicare Physician Fee Schedule will be reduced by 29.5 percent. Doesn't sound like a reasonable business proposition to me.

Second, CMS announced this week that all physicians and providers who completed the enrollment process before March 25, 2011 will once again have to re-validate their enrollment in PECOS. (PECOS may stand for Particularly Exacerbating CMS Online System.) CMS notes that this is to comply with Section 6401(a) of the Affordable Care Act, which increases screening of physicians and providers enrolling in Medicare and Medicaid. (Note: You must complete this work when your Medicare contractor notifies you to do so and not before then, but then you must not be late either. "Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. ")

So what is the alternative? There are three Medicare participation options. The first is to participate, which means enrolling, accepting the Medicare fee schedule for all Medicare patients and being paid directly from Medicare. The second is to enroll but not participate, which allows you to charge the patient a fee up to the Medicare limiting charge and submit a claim for the patient to receive the reduced payment from Medicare. The third is to opt-out of Medicare for periods of two years and privately contract with your Medicare patients. To opt out, a physician must file an affidavit that meets the necessary criteria and is received by the carrier at least 30 days before the first day of the next calendar quarter.

Acknowledging that physicians in hospital-owned or large group practices may not have the luxury of opting out of Medicare, a good business case might be made for individual practices. There is some administrative burden in completing the opt-out affidavit and being sure that the Medicare contractor has validated it and then having each Medicare or Medicare Advantage patient sign a private contract every two years. But that effort should be more than offset by a reduction in many other administrative areas and an improvement to cash flow if a reasonable fee is set based upon actual costs per visit and perhaps a sliding scale for those patients with limited resources. If interested, you can try it out for 90 days and see if it works for your practice. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to their prior status.

What do you think? If you are one of the few physicians who have opted out and still care for Medicare patients, how is it going? Are your patients able to receive equal or better access and quality of care? Do you miss dealing with CMS and their contractors?

Posted at 03:19PM Aug 17, 2011 by Cindy Hughes  |  Comments[0]