CHANGES FOR MEDICAL ONCOLOGY
PRACTICES 2010—WHAT YOU NEED TO
KNOW
Presented by:
Roberta L. Buell, MBA, principal, onPoint Oncology LLC, Sausalito, California
800-795-2633
bbuell@covad.net
Updated May 14, 2010
1
DISCLAIMER
•
Much is not known about Health Reform. This is what we know right now.
•
Payers differ on their guidelines. Please verify coding for each payer and claim.
•
All Medicare and RAC information is literally changing on a daily basis. What is
presented herein may or may not be valid for 2010.
•
This is not legal or payment advice.
•
This content is abbreviated for Medical Oncology. It does not substitute for a thorough
review of code books, regulations, and Carrier guidance.
•
This information is good for the date of the information and may contain typographical
errors.
•
CPT is the trademark for the American Medical Association. All Rights Reserved.
2
SESSION OBJECTIVES
• Discuss Fee Schedule for 2010
• Discuss Timeline For Health Reform
• Discuss the Status of RACs
• Discuss Latest Audits
• Discuss Proposed ICD-9-CM Codes
• Discuss Latest Transmittals
• Discuss Signatures
• Know What You Need to Do Next
3
MEDICARE PHYSICIAN PAYMENT BASICS
•
Payments are based on RVUs for each code (WRVUs+PERVUs+MalRVUs)
•
The pool of RVUs is fixed – any changes must be budget neutral--we had one
of the few exceptions in 2004-2005.
•
RVUs are multiplied times GPCIs for your area. The 1.00 GPCI Floor has
been eliminated.
•
The Medicare conversion factor determines the overall level of Medicare
payments
•
A formula spelled out in the Medicare statute determines the annual update
to the conversion factor and that has been a disaster.
4
WHAT’S HAPPENING TO THE
CONVERSION FACTOR IN 2010?
• The SGR formula which has been flawed for years
signals that we will have a 21.2% DECREASE in
the conversion factor after 4/1/10.
• Physician drugs are now included in the SGR
formula, allegedly skewing it upwards. CMS has
eliminated Part B drugs from the SGR meaning
lower future reductions.
• But, for right now, we are stuck with a conversion
factor of $28.3895 down from $36.0666 after the 2
month hold. For 3 months, CF = $36.0846
5
The SGR Saga
•
Was pulled out of the House and Senate bills because of cost: $210-240 billion to fix, not patch, the SGR
•
House passed a separate “fix” bill but Senate failed
•
•
•
2-month patch in the defense bill averted the 21.2% Medicare cut until 3/1--CMS holds Medicare claims
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House passes an “extenders” bill including 30-day patch through 4/1 (also included COBRA and unemployment
insurance extensions)
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Senate unable to pass the bill before 3/1 over Senator Bunning’s objections
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CMS holds claims for 10 days
•
Senate passes bill
House passes another “extenders” bill including 30-day patch through 5/1 (also includes COBRA and
unemployment insurance extensions)
•
Attempt to go back to the House with changes to the bill fails. House leaves on 2-week recess
•
Senate unable to pass the bill over Senator Coburn’s and unified GOP objections; Senate leaves on 2-week recess
•
CMS holding claims for 10 days
•
Senate returns on 4/12 to take up measure
•
Senate passes the bill, followed by House passage and President signs into law.
•
Provides a patch till 6/1
A true SGR fix unlikely; most likely scenario is 5-year patch — maybe following 4-7 month patch
the Senate Budget Resolution
From:Ted Okon’s Health Reform Slides
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5-year patch in
What Will You Do?
• Frank Cohen Study (www.frankcohen.com)
• Over 33% said they would go non-PAR
• Over 2/3rds will limit Medicare patients
• Over 2/3rds will re-negotiate any contract based on
Medicare rates
• A Sermo survey of 1500 physicians showed 84% of
physicians will stop seeing patients if the cuts go
through…
7
IMPACT OF 2010 MPFS CHANGES
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Health Reform
• 2010 Provisions
• Immediate access for patients with pre-existing conditions:
High risk pools will be formed in June to take care of these
folks.
• Practices with imaging must provide their patients with a
statement evidencing facilities where they can get same
services. This dates back to January 1.
• Small business tax credits: Small businesses can get tax
credits for insurance, up to 35% but the average salary must
be $40K or less.
• Prohibition of rescissions: Prohibits insurers from
retroactively denying access based on current or previous
diagnoses.
• Claims filing limit to Medicare will be one year.
9
Health Reform
• 2010 Provisions (Cont’d)
• Begins to eliminate lifetime limits and restricts use of
annual limits: This will start in September, making
insurance verification easier.
• Dependent coverage extended to the age of 26: Starts
September of 2010.
• Doughnut hole starts to close a little. Patients who
enter this year will get a $250.00 rebate. In 2011, there
will be a 50% discount on all brand name drugs.
During the next ten years, the gap will go from 100% to
25% coinsurance in 2020.
10
Health Reform
• 2010 Provisions
• GPCI Floor extended in 2010. Work RVU adjustment
at 1.00 in 2010. Adjustments in 2011 for frontier states.
• Medicare Independent Payment Advisory Board
established. This Board will oversee Medicare with 15
members who will take over some Congressional
duties.
• Expansion of Medicaid. A new option is established to
allow states to fund patients at 133% FPL.
• Encourages new therapies for acute and new
therapies with $1 billion cap for credits.
11
Health Reform
• 2010 Provisions (Cont’d)
• Special provision of Blue Cross/Blue Shield which
states that the non-profit Blues must a a medical loss
ratio of 85%. That means that to keep their non-profit
status they must spend 85% on care.
• Imaging will take reductions of 50% of the –TC for
multiple procedures at an increased rate of 50%
starting July 1.
• Indoor tanning gets taxed by 10%. Lotions, gels, and
spray on tans are not taxed.
12
Health Reform
• 2011 Provisions
• PQRI is extended through 2014 and then becomes
mandatory. You get 1% in 2011 and 0.5% 2012-2014;
then, the hammer comes down in 2015, you get -1.5%
for non-participation and -2% thereafter.
• Increased reimbursement for primary care with a 10%
incentive for all physicians listed with Medicare as
family medicine, internal medicine, and pediatrics
where 60% of charges are concentrated in the office.
This will be around 2011-2016.
• 10% bonus for surgeons in HPSA areas.
13
Health Reform
• 2011 Provisions (Cont’d)
• Improves preventative care by eliminating co-pays
and deductibles for preventative services. Not clear
yet what these are.
• Development of a Physician Compare web site. Opens
in 2013.
• Employers must report health benefits on W-2.
• Pharma writes big checks. Imposes an annual, nondeductible fees on firms that have BRANDED
pharmaceuticals with revenues over $5 million.
14
Health Reform
• Provisions 2012-2013
• Encouragement of Accountable Care Organizations
(ACOs). More about this in a minute.
• Administrative simplification starts again. This will be to
standardize claims, verification, prior auth, and all
remittance processing. But, this must be enforced.
• Practice expense adjustments for geographical differences.
• No more employer subsidies for Part D.
• Tax deductions for health insurance expense will go from
10% to 7.5% unless you are over 65.
• Increased Medicare tax on individuals. Will be 2.35% on
wages; 3.8% on unearned income.
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Accountable Care Organizations
Beginning January 1, 2012, groups of qualifying providers will have the opportunity to form
Accountable Care Organizations (ACOs) and share in cost savings they achieve for Medicare
program. Providers include:
Physician group practice arrangements
Networks of practices
Hospital-physician joint ventures
Hospitals employing physicians and other clinical professionals (physician assistants,
nurse practitioners, or clinical nurse specialists)
Accountable Care Organizations
To qualify as an ACO, an organization must:
• Agree to become accountable for the overall care of their Medicare
fee-for-service beneficiaries
• Agree to a minimum three-year participation per cycle
• Have a formal legal structure enabling it to receive and distribute
bonuses to participating providers
• Provide information on the physicians participating in the ACO
• Have a management and leadership structure in place
• Define processes to promote evidence-based medicine and patient
engagement, report on quality and cost measures, and coordinate
care
• Demonstrate that it meets any patient-centeredness criteria
determined by the HHS Secretary
Health Reform
• 2014 Provisions
• The hammer comes down on insurance companies.
Strong provisions will be enforced to ensure access
regardless of health status. Limits on coverage will be
eliminated. Premium variability will be minimized.
• Health Insurance Exchanges will be established.
These will be set up in each state to assure affordable
coverage for individuals and small business.
• Coverage of individuals and routine costs associated
with clinical trials.
18
Health Reform
• 2014 Provisions (Cont’d)
• Penalties will be levied for no insurance. This is being
legally challenged in several states.
• Payers pay up. Health insurers will pay according to
market share, if they have premiums over $25 million.
• IPAB submits recommendations to curb spending, if
costs are greater than inflation.
• Medicaid expansion is implemented.
19
Health Reform
• 2015 Provisions
• Independent Payment Advisory Board submits
‘proposals’ to Congress to ‘increase solvency’ of the
Medicare Program.
• Physicians will ‘paid on value’ not volume. Valuebased pricing will kick in.
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The Future of PQRI
• Health Reform reinforced PQRI for the foreseeable
future.
•
•
•
•
1% in 2011
0.5% in 2012-2014; still voluntary
2015: -1.5% for non-participation
After 2015: -2.0%
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E-PRESCRIBING: THE CARROT AND THE STICK
Year
Successful**
Not
2009
2%
0%
2010
2%
0%
2011
1%
0%
2012
1%
-1%
2013
0.5%
-1.5%
2014+
0%
-2%
In 2009 and 2010, physicians who successfully e-prescribe may receive a bonus payment of 2 percent of their overall
Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a potential bonus of 4 percent
in Medicare reimbursement.
***No double incentives for those participating in the ARRA EMR incentive program.
22
Oncology Issues
•
Blood Transfusion Units of Service
•
IV Hydration Units of Service
•
Neulasta Units of Service
•
Pump/Pump Supplies
•
Facility versus Non-Facility
•
SNF Billing
•
A4221 Units of Service
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Global versus –TC, -TC in facility
•
CSW During Inpatient
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Services to Hospice Patients
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“New” versus Established patients
•
DME Charged After date of Death
•
MUEs (Connelly)
These are changing daily—Check the Web Site often
23
Other Audits
• High dollar claims—WPS
• 99211 and Coumadin checks----WPS
• Non-chemo drugs with chemo admin codes (20052007)—Palmetto GBA
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KNOW WHERE PREVIOUS IMPROPER
PAYMENTS HAVE BEEN FOUND
• Look to see what improper payments were found by
the RACs:
• Demonstration findings: www.cms.hhs.gov/rac
• Permanent RAC findings: will be listed on the RACs’
websites
• Look to see what improper payments have been
found in OIG and CERT reports
• OIG reports: www.oig.hhs.gov/reports.html
• CERT reports: www.cms.hhs.gov/cert
25
New ICD-9 Codes 10-1-2010
• New Hem-Onc Codes
•
•
•
•
•
•
•
•
•
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Red blood cell disorders (275.0_)
Transfusion circulatory overload (276.61)
Post-transfusion purpura (287.41)
Other secondary thrombocytopenia (287.49)
Febrile non-hemolytic transfusion reaction (780.66)
Jaw pain (784.92)
Hemoptysis, unspecified (786.30)
Feces disorders (787.6_)
Transfusion reactions (999.6_-999.8_)
Do not resuscitate status (V49.86)
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Deleted ICD-9-CM Codes 10-1-2010
• Iron Disorders (275)
• Fluid disorders (276.6)
• Secondary thrombocytopenia (287.4)
• Hemoptysis (786.3)
• Incontinence of feces (787.6)
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PECOS
• Claims ordered / referred must:
• NPI of ordering provider
• Name in PECOS or MAC system
• Specialty as listed
• Grace Period
• Phase 1: 10/5/09 to 1/2/11 warning message on remittance
• Phase 2: 1/3/11 and after: claim rejected if referring
individual not in Pecos or MAC list
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PECOS
• To assist providers in their quest to get physicians enrolled in
PECOS, the Part B MACs will be sending revalidation letters to all
physicians who have not updated their Medicare enrollment in over
6 years. (Medicare contractors first began updating the PECOS
database with physician enrollments in November of 2003;
therefore, physicians enrolled prior to this date will not be in the
database.). The letter will instruct the physician to submit either an
updated paper enrollment form or to enroll online via PECOS.
• Revalidation of some labs
• Need to update any changes within 30 days
• Address, phone, suite
• New members in group
• Other changes
• If no claims to Medicare in one year—physician is
disenrolled in Medicare
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Drug Waste
• Transmittal 762, Change Request 6711, effective July
30, 2010
• Use of –JW still optional at discretion of Carrier
• Depends upon J-code. Let’s say J-code is 1 mg. You
use 9 mg and waste 1 mg. You would bill 2 lines
• 9 units on one line
• 1 unit with –JW on another line
• But, if the J-code is 10 mg, you would just bill the one
line.
• Must document waste in either case.
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Imaging Reduction
• Transmittal 694, CR 6965, effective July 1 and
implemented July 6, 2019
• Implements Health Reform Provision
• Reduction of –TC increased from 25% to 50% for
additional procedures done in the same session on the
same day.
• Many experts thought this would not happen until
2011.
31
Claims Filing
•
Transmittal 697, CR 6960, effective January 1, 2010 and
implemented October 4, 2010
•
Claims must be filed within one calendar year. Implementation
will be according to this schedule:
• 1) claims with dates of service prior to October 1, 2009 will be subject
to pre-PPACA timely filing rules and associated edits;
• 2) claims with dates of service October 1, 2009 through December 31,
2009 received after December 31, 2010 will be denied as being past the
timely filing statute and;
• 3) claims with dates of service on or after January 1, 2010 received
more than 1 calendar year beyond the date of service will be denied as
being past the timely filing statute (ex: claim DOS = 3/15/10, claim
must be received by COB 3/15/11).
• One exception is a mistake by CMS or agents thereof.
32
Signatures: Review Criteria
•
Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that
were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that
stamped signatures are not an acceptable form of authentication. The previous language in the CMS Program Integrity Manual
required a “legible identifier”. The recent CMS Transmittal 327 has added additional clarification and signature assessment
requirements.
•
If the reason for a pre- or post-payment denial is unrelated to the signature requirement, the contracted reviewer can
disregard the signature authentication process. However, if the criteria in the specific Medicare policy cannot be met
because the documentation is missing a signature or it is not legible, the reviewer is instructed to proceed to the signature
assessment procedure.
•
If the signature is missing from an order, the reviewer has been instructed to disregard the order during the review of
the claim.
•
If the signature is illegible, the reviewer can request a signature log or attestation statement to determine the identity of the
author of a medical record entry. Although there is not a specific attestation form at this time, the transmittal does provide
specific language that should be considered if the provider is using this process.
•
If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a
signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical
record “beyond the short delay that occurs during the transcription process” and should instead use the signature
attestation process. Other providers in the same group may not attest to the original author’s signature.
•
In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to
ensure that the rest of the documentation contains enough information to determine the date when the service was ordered
and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however,
the second order on the same page is not dated. It could be assumed that the second order occurred on the same date.
•
All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering
the medical record complete.
•
Providers should also be reviewing all documentation prior to sending medical record copies to contractors for review. If
a signature is not legible or is missing, the providers should take the appropriate steps to comply with the requirement in
advance to prevent delays regarding the outcome of the review. Also, review all request letters for any additional language the
reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional
Documentation Request (ADR).
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SURVIVAL STRATEGIES
•
Cash is the practice’s most vital resource. Make sure you have your cash requirements in mind with every
decision you make. Do not live beyond your means.
•
Remember that collections start with the referral and ends with payment. Collections also start at the top with
the physicians. Patients should pay balances with every encounter.
•
Do not get behind in your payments to distributors. This is the beginning of the end of your survival. Nobody
is your friend if you owe them money.
•
Ensure that your billing system is sophisticated enough to meet your needs. You need to keep close tabs on
your production by code, your DSO, and your Accounts Receivable. This system is your lifeline.
•
Practices with imaging must be giving the patients a statement RIGHT NOW. Examples on COA web site.
•
Run the numbers, if you have imaging, for the July reduction.
•
Check the signatures in your records for compliance.
•
If you haven’t participated in PQRI, use a REGISTRY.
•
Start getting prepared for “meaningful use” HIT incentives and direct submission of PQRI data. Get with
your EMR vendor!
•
Make sure you are prepared for more cash flow interruptions.
•
Participate in the struggle! The fight is not over yet!
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• CAN Web Site
• The latest news
• Forms
• Regulations
• Newsletters
• Presentations
• http://communityoncology.info
35
CONTACT INFO
• Contact
• bbuell@covad.net
• bobbibuell1@yahoo.com
• 800-795-2633
• Newsletter is free!
• Send all RAC information to me at the ABOVE E-mails
or FAX to 650-618-8621
• Go to our website: http://www.onpointoncology.com
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THANK YOU FROM ONPOINT ONCOLOGY LLC!
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