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MEDICARE UPDATE WSMOS

MEDICARE UPDATE WSMOS . March 11 2011 Bernice Hecker, MD, MHA, FACC . Overview. CMS & ACA: Increase access to valuable services Identify Value Pay for Value Programs LCDs (Comparative Effectiveness) Control Costs MAC Prevention of Disease PFS Changes

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MEDICARE UPDATE WSMOS

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  1. MEDICARE UPDATE WSMOS March 11 2011 Bernice Hecker, MD, MHA, FACC

  2. Overview CMS & ACA: Increase access to valuable services Identify Value Pay for Value Programs LCDs (Comparative Effectiveness) Control Costs MAC Prevention of Disease PFS Changes Anti Fraud & abuse (MD Signatures, OIG) ) Januar11 NAS, LLC Proprietary 2

  3. CMS: Cares about Medicare Service(s) NAS, LLC Proprietary • CMS attitudes = Congressional beliefs • Sky high costs and plummeting access • MDs as key to access & cost • Help or Hindrance • CMS comments • Assist local Contractors • Medical society advocacy • AMA/other

  4. INCREASE ACCESS: ACA NAS, LLC Proprietary • Shift dollars by shifting incentives • Pay for Value • LCDs & other comparative effectiveness efforts • Specialists vs. primary care • Payment reform • PFS changes • ACO • Medical Home

  5. COST CONTROL NAS, LLC Proprietary • MAC • FAR & Competitive Bidding • Consolidation • Staff efficiencies and reductions • ACA • Prevention of disease • Delivery system • Payment reform • Fraud & abuse

  6. VALUE

  7. Physician Quality ReportingSystem (PQRS) Reminder January 2011 NAS, LLC Proprietary 8 • Formerly referred as PQRI (Incentive) • 1% payment bonus continues for 2011 • 194 total measures • 5 new measures – claims/registry reporting • 11 new registry – only measures • 4 new measures - Electronic Health Records (EHR) based reporting only • 5 deleted measures • 20 EHR measures • 14 measures groups (e.g. Asthma = new measure)

  8. LCDs 1/3 NAS, LLC Proprietary • Draft • B-Natriuretic Peptide (BNP), comment 4/22 • Vertebral Augmentation Procedures • Retirements • CT Colonography • MD CTA (Multidetector CT Angiography) • Plastic Surgery • Artificial Disc (Non-Covered Services) • Endoscopic Treatment of GERD (Non-Covered Services LCD)

  9. LCDs 2/3 NAS, LLC Proprietary • Retirements (cont.) • Stereotactic Body Radiation Therapy • Stereotactic Computer-assisted Volumetric Navigation • Treatment of OSA • Wireless Capsule Colonography

  10. LCD 3/3 NAS, LLC Proprietary • Potential LCDs • ESI (Epidural Steroids) • Vitamin D Assays • Data Analyses

  11. Dollars

  12. COST CONTROL NAS, LLC Proprietary • MAC • FAR & Competitive Bidding • Consolidation • Staff efficiencies and reductions • ACA • Prevention of disease • Delivery system • Payment reform • Fraud & abuse

  13. MAC: Phase 2 NAS, LLC Proprietary • 15 A/B MAC Jurisdictions • 9/15 implemented • 6/15 in protest or corrective actions • 2, 6, 8, 11,15 • J2 (WA) award – Summer 2011 • Re-Bids began last summer - J3 • Consolidation – 15 to 10 • Jur2 + Jur3 = Jur F

  14. 14 2 3 13 6 12 8 1 5 15 11 4 10 7 2 9 1 = Start-up 3 = Cycle One N = Cycle Two N New A/B MAC Jurisdictions

  15. Five Consolidated A/B MAC Contracts • JURISDICTION F- A/B MAC Jurisdictions 2 and 3 (Alaska, Washington, Oregon, Idaho, North Dakota, South Dakota, Montana, Wyoming, Utah, and Arizona) • Jurisdiction H- A/B MAC Jurisdictions 4 and 7 (Louisiana, Arkansas, Mississippi, Texas, Oklahoma, Colorado, and New Mexico) • Jurisdiction G- A/B MAC Jurisdictions 5 and 6 (Minnesota, Wisconsin, Illinois, Kansas, Nebraska, Iowa, and Missouri) • Jurisdiction I- A/B MAC Jurisdictions 8 and 15 (Kentucky, Ohio, Michigan, and Indiana) • Jurisdiction K- A/B MAC Jurisdictions 13 and 14 (New York, Connecticut, Massachusetts, Rhode Island, Vermont, Maine, and New Hampshire)

  16. A/B Contracts that are not consolidated • Jurisdiction E- A/B MAC Jurisdiction 1 (California, Hawaii, Nevada, Pacific Islands) • Jurisdiction N- A/B MAC Jurisdiction 9 (Florida, Puerto Rico, US Virgin Islands) • Jurisdiction J- A/B MAC Jurisdiction 10 (Alabama, Georgia, Tennessee) • Jurisdiction M- A/B MAC Jurisdiction 11 (North Carolina, South Carolina, Virginia, West Virginia) • Jurisdiction L- A/B MAC Jurisdiction 12 (Delaware, Maryland, Pennsylvania, New Jersey, Washington DC)

  17. Impact: Medical Director NAS, LLC Proprietary • Competition – sharing • Ongoing reassessment of values • U.S., CMS, NAS, personal • More work with less staff • Community support • Risk • Assistance • Idealism vs. Realism

  18. COST CONTROL NAS, LLC Proprietary • MAC • FAR & Competitive Bidding • Consolidation • Staff efficiencies and reductions • ACA: “Affordable Care Access” • Prevention of disease • Delivery system: EHR • Payment reform • Fraud & abuse

  19. Preventive Services NAS, LLC Proprietary • Effective January 1, 2011 • Part B deductible and coinsurance will be waived for most preventive services • Provision waives both for preventive services with a grade of A or B by U.S. Preventive Service Task Force (USPSTF) • Deductible will be waived for tests that begin as screening and change to diagnostic or therapeutic services • I.e. colorectal cancer screening • CR7012

  20. Screening Recommendations NAS, LLC Proprietary • Several preventive services covered by Medicare do not have a USPSTF recommendation grade of A or B • Barium enemas provided as colorectal cancer screening tests, coinsurance applies • Screening barium enema, deductible is waived under another section of statute • Deductible and coinsurance apply: • Digital rectal examinations provided as prostate screening tests • DSMT services • Glaucoma screening • Screening electrocardiograms performed for IPPE • Deductible and coinsurance continues to apply to other services

  21. Annual Wellness Visit NAS, LLC Proprietary January 2011 24 • CR 7079 may include the following: • Establish/update medical/family history • List providers/suppliers/medications • Record measurements of height, weight, body mass index, blood pressure & other routine measurements • Detect any cognitive impairment • Establish/update a screening schedule for patient to follow over next 5-10 years • Furnish personalized health advice and appropriate referrals to health education

  22. New Covered Preventive Service – Annual Wellness Visit 2 NAS, LLC Proprietary • G0438 – Annual wellness visit, including personalized prevention plan services, first visit • Paid at level 4 office visit for new patient (similar to IPPE) • G0439 – Annual wellness visit, including personalized prevention plan services, subsequent visit • Paid at level 4 office visit for established patient

  23. COST CONTROL NAS, LLC Proprietary • MAC • FAR & Competitive Bidding • Consolidation • Staff efficiencies and reductions • ACA: “Affordable Care Access” • Prevention of disease • Delivery system: Electronic magic • Payment reform • Fraud & abuse

  24. Electronic Health Records (EHR) NAS, LLC Proprietary

  25. EHR Payment Adjustments NAS, LLC Proprietary • 2015 payment adjustments begin • EPs do not successfully demonstrate “meaningful use” of certified EHR technology • Payment adjustments will be: • 2015 – 99% of MPFS allowed amount (80%) • 2016 – 98% • 2017 – 97% • By 2018 and subsequent years, if less than 75% of EP’s are meaningful users, payment will change by 1% each year until adjustment reaches 95%

  26. E-Prescribe (eRx) NAS, LLC Proprietary • Electronic transmission of prescriptions • Takes place between a prescriber, dispenser, pharmacy benefit manager or health plan • Can take place through an intermediary – eRx network • Began in 2009 – came from MIPPA legislation • Medicare Improvements for Patients and Providers Act of 2008 • Promotes adoption/use of eRx systems • eRx provides a combination of incentives and payments adjustments for providers who are not successful electronic prescribers • Details: http://www.cms.gov/ERXincentive

  27. Electronic Prescribing (E-Prescribing or eRx) Reminder January 2011 NAS, LLC Proprietary 30 1% incentive bonus continues for eligible electronic prescriptions Individual “eligible providers” must still meet qualified system standards Group option broadened (less than 200) 2012 starts imposed payment adjustment

  28. eRx2 NAS, LLC Proprietary

  29. COST CONTROL NAS, LLC Proprietary • MAC • FAR & Competitive Bidding • Consolidation • Staff efficiencies and reductions • ACA: “Affordable Care Access” • Prevention of disease • Delivery system • Payment reform • Fraud & abuse

  30. Reform: Shift Incentives NAS, LLC Proprietary • Primary Care & Gen Surg incentives • Increase access, prevent or early treatment • Medical Home • PFS (Examples) • Bundling of services (card, radonc) • Imaging Families and TC ↓ • RVU updates • MEI Re-basing • ACOs

  31. Multiple Procedure Payment Reduction on TC of Certain Diagnostic Imaging Procedures NAS, LLC Proprietary • Effective January 1, 2011 • CMS is consolidating existing 11 advanced imaging families into a single family • Applies: • When two or more services on list are furnished to same patient in a single session • Only to Technical Component (TC) portion of global services • Full TC payment for procedure with highest priced TC • 50% for TC of each additional procedure on same patient in same session • CR6993

  32. RVUs NAS, LLC Proprietary • RVU = Work, PE, PLI x conversion factor • PPIS (Phys Pract Info Survey) – year 2/4 • Practice Expenses • MEI (Medicare Economic Index): • ↓ Work 52.466 to 48.266) • ↑PE (43.669 to 47.439) • ↑PLI (3.865 to 4.295) EX: ↑RadOnc

  33. RVUs: Impact on Oncologists NAS, LLC Proprietary • E&M – variable • Drug Administration – 0-1% ↓ • Capture office expense • Know the Fee Schedule

  34. Fee Schedule Lookup Tool January 2011 NAS, LLC Proprietary 37 • Medicare Physician Fee Schedule (MPFS) tool • CMS enhanced search http://www.cms.gov/apps/physician-fee-schedule/overview.aspx • MPFS Search Help • http://www.cms.gov/apps/physician-fee-schedule/help/Medicare-Physician-Fee-Schedule-Search-Help.pdf

  35. The investigator and You NAS, LLC Proprietary

  36. Signature on Requisitions for Clinical Diagnostic Lab Tests  NAS, LLC Proprietary • November 29, 2010 Federal Register final rule proposed policy to require a physician’s or Non Physician Practitioner’s (NPP’s) signature on requisitions for clinical diagnostic laboratory tests paid under clinical laboratory fee schedule • First quarter of 2011, CMS will develop education and outreach materials to build awareness and understanding in physician community • Once first quarter educational campaign is fully underway, CMS will expect requisitions to be signed • http://www.cms.hhs.gov/ClinicalLabFeeSched • JSM/TDL 11097 dated December 20, 2010

  37. 2011 OIG FOCUS NAS, LLC Proprietary • Place of Service (POS) errors • Services performed in Ambulatory Surgery Centers (ASCs) and hospital outpatient settings • Coding & payments for Evaluation and Management (E/M) services • E&M services during global surgery periods • Portable x-ray suppliers billing • Outpatient physical therapy services provided by independent therapists • Questionable billing for outpatient therapy services • Excessive payments – unusually high claim amounts

  38. 2011 OIG FOCUS 2 NAS, LLC Proprietary Appropriateness of payments for polysomnography Payments for sleep testing Lab test unbundling by clinical labs Billings with modifier GY Medicare Secondary Payments (MSP)/other insurance coverage Brachytherapyreimursement Observation services during outpatient visits Part B payments for home health beneficiaries

  39. 2011 OIG FOCUS 3 NAS, LLC Proprietary Services performed by Clinical Social Workers (CSWs) Excessive payments for diagnostic tests Laboratory test unbundling by clinical laboratories Geographic areas with high density of IDTF’s Error-prone providers: Medicare Part A & B CERT for FY 2010 error rate oversight http://www.oig.hhs.gov/publications/workplan/2011/

  40. Region D Contractor • HealthDataInsights, Inc. • 7501 Trinity Peak Street, Suite 120 Las Vegas, NV 89128-6896 888-700-3282 http://www.healthdatainsights.com/index.aspx • Subcontractor: PRG Schultz, Inc. NAS, LLC Proprietary

  41. CMS RAC Information • CMS Web Site: www.cms.hhs.gov/RAC • CMS RAC Email: RAC@cms.hhs.gov NAS, LLC Proprietary

  42. CERT Help • Websites: • CMS: • http://www.cms.hhs.gov/CERT/ • Noridian: • http://www.noridianmedicare.com NAS, LLC Proprietary

  43. Appeal, Appeal, Appeal! • If you disagree with the outcome of the CERT review, appeal the claim! • Appeals will be processed by NAS • No amount is too small, and the outcome may dramatically reduce your facility error rate NAS, LLC Proprietary

  44. Thank You….. What Questions Do You Have?

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