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
– Anti Fraud & abuse (MD Signatures, OIG)
Januar11
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CMS: Cares about Medicare
Service(s)
•
•
•
•
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
Winter 2011
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INCREASE ACCESS: ACA
• Shift dollars by shifting incentives
– Pay for Value
– LCDs & other comparative effectiveness
efforts
– Specialists vs. primary care
• Payment reform
– PFS changes
– ACO
– Medical Home
Winter 2011
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COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA
– Prevention of disease
– Delivery system
– Payment reform
– Fraud & abuse
Winter 2011
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VALUE
Physician Quality Reporting
System (PQRS)
• 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)
January 2011
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LCDs 1/3
• 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 (NonCovered Services LCD)
Winter 2011
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LCDs 2/3
• Retirements (cont.)
– Stereotactic Body Radiation Therapy
– Stereotactic Computer-assisted Volumetric
Navigation
– Treatment of OSA
– Wireless Capsule Colonography
Winter 2011
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LCD 3/3
• Potential LCDs
– ESI (Epidural Steroids)
– Vitamin D Assays
• Data Analyses
Winter 2011
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Dollars
COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA
– Prevention of disease
– Delivery system
– Payment reform
– Fraud & abuse
Winter 2011
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MAC: Phase 2
• 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
Winter 2011
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New A/B MAC Jurisdictions
14
2
3
13
6
12
8
1
5
15
11
4
10
3 = Start-up
7
N = Cycle One
2
9
1
N = Cycle Two
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)
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)
Impact: Medical Director
• Competition – sharing
• Ongoing reassessment of values
– U.S., CMS, NAS, personal
• More work with less staff
• Community support
– Risk
– Assistance
– Idealism vs. Realism
Winter 2011
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COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA: “Affordable Care Access”
– Prevention of disease
– Delivery system: EHR
– Payment reform
– Fraud & abuse
Winter 2011
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Preventive Services
• 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
January 2011
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Screening Recommendations
• 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
January 2011
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Annual Wellness Visit
• 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
January 2011
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New Covered Preventive Service
– Annual Wellness Visit
2
• 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
January 2011
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COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA: “Affordable Care Access”
– Prevention of disease
– Delivery system: Electronic magic
– Payment reform
– Fraud & abuse
Winter 2011
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Electronic Health Records (EHR)
Calendar
Year
Maximum Incentive Payments Based on the First CY
an EP Participates in the Program
2011
2012
2013
2014
2011
$18,000
2012
$12,000
$18,000
2013
$8,000
$12,000
$15,000
2014
$4,000
$8,000
$12,000
$12,000
2015
$2,000
$4,000
$8,000
$8,000
$2,000
$4,000
$4,000
$44,000
$39,000
$24,000
2016
Total
$44,000
For more information: http://www.cms.gov/EHRIncentivePrograms/
January 2011
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EHR Payment Adjustments
• 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%
January 2011
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E-Prescribe (eRx)
• 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
January 2011
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Electronic Prescribing
(E-Prescribing or eRx)
• 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
January 2011
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eRx
2
Medicare Incentives for eRx
2011
1% Incentive payment
2012
1%
2013
0.5%
eRx Payment Adjustments may occur for not being a successful
electronic prescriber
2012
Receive 99% of EP or group practice Part B covered services
2013
Receive 98.5%
2014
Receive 98%
It is possible to receive an eRx incentive payment for 2011 AND an
eRx payment adjustment for 2012
January 2011
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COST CONTROL
• MAC
– FAR & Competitive Bidding
– Consolidation
– Staff efficiencies and reductions
• ACA: “Affordable Care Access”
– Prevention of disease
– Delivery system
– Payment reform
– Fraud & abuse
Winter 2011
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Reform: Shift Incentives
• Primary Care & Gen Surg incentives
– Increase access, prevent or early treatment
– Medical Home
• PFS (Examples)
– Bundling of services (card, rad onc)
– Imaging Families and TC ↓
– RVU updates
• MEI Re-basing
• ACOs
Winter 2011
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Multiple Procedure Payment Reduction on
TC of Certain Diagnostic Imaging
Procedures
• 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
January 2011
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RVUs
• 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: ↑Rad Onc
Winter 2011
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RVUs: Impact on Oncologists
• E&M – variable
• Drug Administration – 0-1% ↓
• Capture office expense
– Know the Fee Schedule
Winter 2011
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Fee Schedule Lookup Tool
• Medicare Physician Fee Schedule
(MPFS) tool
• CMS enhanced search
http://www.cms.gov/apps/physician-feeschedule/overview.aspx
• MPFS Search Help
– http://www.cms.gov/apps/physician-feeschedule/help/Medicare-Physician-FeeSchedule-Search-Help.pdf
January 2011
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The investigator and You
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Signature on Requisitions for
Clinical Diagnostic Lab Tests
• 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
January 2011
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2011 OIG FOCUS
• 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
January 2011
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2011 OIG FOCUS
2
• 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
• Brachytherapy reimursement
• Observation services during outpatient visits
• Part B payments for home health beneficiaries
January 2011
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2011 OIG FOCUS
3
• 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/
January 2011
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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.
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CMS RAC Information
• CMS Web Site: www.cms.hhs.gov/RAC
• CMS RAC Email: RAC@cms.hhs.gov
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CERT Help
• Websites:
– CMS:
• http://www.cms.hhs.gov/CERT/
– Noridian:
• http://www.noridianmedicare.com
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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
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Thank You…..
What Questions
Do You Have?