WITH HEALTH EXCHANGES and
MEDICAID EXPANSION, UP is the
NEW UP for 2014 and BEYOND
Ed Gaines, JD –
Chief Compliance Officer, Medical Management Professionals
David McKenzie, CAE –
Reimbursement Director, ACEP
Learning Objectives:
Identify the key areas to prepare your
practice for the new healthcare
reimbursement environment.
Describe the evolving health exchange
plan programs.
Develop strategies to prosper under
PQRS reporting methodologies.
Flat is the
new up!!
3
That phrase was so last year—and
we really really want it retired.
4
2013-15 Healthcare Reform
Timeline: our agenda today.
2013
1Q
2Q
2014
3Q
US DHHS approval of exchange
options by states ongoing-2/15/13 “go/no go decision”
for SPE.
4Q
10/1/13: health exchange
eligibility systems must
go live.
State Medicaid Section
1115(b) waivers are being
submitted to reform MCD
while MCD expansion looms.
Medicaid Primary Care
Incentive Payment (PCIP) pays
the difference between Medicaid
and Medicare for FP, IM and
Pediatrics for ‘13 and ‘14.
1Q
2Q
2015
3Q
PPACA exchange
policies are effective
1/1/14.
4Q
Per SCOTUS,
States have Medicaid
expansion discretion—100%
Federal $ for newly eligible.
ICD-10 required
as of 10/1/14 DOS.
IRS enforcement of
penalties/tax for
failure to obtain
Individual policy.
1Q
2Q
4Q
Issue whether “crowd out”
effect will be begin with
loss of ESI.
2015: MD payments
decreased by 1.5% (2% in
following years) for
non-participation in PQRS
In 2013.
Under PPACA,
hospital DSH payments
are reduced over time, further
pressuring states
to expand Medicaid.
National pilot program
payment bundling
Hosp. , doctors & post-acute
providers.
5
3Q
5
Pre-PPACA and PPACA
Critical Concepts:
 Pre-PPACA, Medicaid
cover those lawfully
present for < 5 yrs., childless, non-disabled
and non-elderly + parents whose incomes are
>100% of FPL.
 As written, PPACA changes the Medicaid
coverage to modified adjusted gross income
(MAGI) and eliminates other requirements.
 PPACA mandates Medicaid expansion for
those between 100-138% of FPL—pre-Supreme
Court decision.
6
A brief historical review. The ACA’s
Mandatory vs. Discretionary
Provisions.
 National Federation of Independent Business (NFIB) v.
Sebelius, challenged PPACA.
 In June 2012, The Supreme Court of the US (SCOTUS)
finds the PPACA’s individual mandate to purchase
health insurance constitutional.
 Penalties for failure to purchase health
insurance=tax.
 Medicaid expansion cannot be mandated by the feds
w/ threat of losing matching funds—states may decide
to
eligibility to 138% of FPL.
7
http://www.familiesusa.org/resources/tools-for-advocates/guides/federal-povertyguidelines.html
8
How HIEs and Medicaid Expansion
Could Impact the State’s Uninsured:
One case study.
NC population 9.5 million in 2011—10th in
US.
1.5 Million uninsured—7th in the US.
606K between 139%-399% of FPL.
Medicaid participation rates nat’l average
is 61.7%, NEJM 2010, B. Sommers & A.
Epstein.
9
2013 Medicaid Eligibility:
One Case Study: NC
250
200
150
100
NC Health Choice
50
Medicaid
0
10
Medicaid Eligibility Under
Expansion to 138% of FPL: the
yellow area could be any state.
250%
200%
150%
100%
Optional Coverage
Existing NCHC
Newly Medicaid Eligibles
50%
Existing Medicaid Eligibles
0%
11
State decisions not to expand MCD
may be changed—e.g. FL, AZ, OH
and NJ.
12
Case Study: how Medicaid will expand anyway
under the PPACA.
2014-2019
MCD “Woodwork” Newly eligibles:
(existing eligibles) 100-138% FPL
Eligibles
70-84K (14%)
494-526K (86%)
610K by 2019
NC State
Expenditures.
$560 Million*
$96 Million.
$656 Million.
Federal
$2.0 Billion
$11.5 Billion
$13.5 Billion
Total
$2.56 Billion**
$11.6 Billion
$14.1 Billion


Totals
*Includes all service costs, offsets of SCHIP and administrative costs. Source: NC Institute of Medicine.
**Woodwork happens whether the state expands Medicaid to the newly eligibles or not.
13
What is the health insurance
exchange (HIE) under the PPACA?
 An organized marketplace where individuals
and small-business owners can view,
compare, and purchase qualified private
health plans.
 Most consumers will shop on their state’s
exchange online, but they can also shop by
phone or through brokers.
 The exchanges’ “shop and compare”
functions must be operational by 10/1/13, w/
coverage effective 1/1/14.
14
State Based Exchange
(SBE)
• State operates all
exchange functions;
• SBE governance, plan
management, consumer
assistance/phone
center, “Navigator”
functions, eligibility
determinations and
additional state
coverage options set by
the state.
• SBEs have to be
approved by DHHS
• Utah model shows
flexibility in design;
• State may use feds. for
risk adjustment and
reinsurance.
• 18 States have filed for
SBE.
HIE Options:
State Partnership
Exchange (SPE)
• Hybrid model w/ state
option to perform critical
eligibility functions.
• Plan management,
consumer assistance
and “Navigator”
functions at federal level.
• Federal grant funding for
exchange creation
available in 2013-14, as
of 2015 HIEs must self
funded.
• CMS established 3.5%
user fees to health plans
in SPEs and FFEs.
• Risk adjustment &
reinsurance may be state
or federal.
• Option to “buy time” to
access funding, create
systems and transition to
SBE in future.
• 7 states have SPEs.
Federally facilitated
Exchange (FFE)
• Feds operate all
essential elements of
HIE;
• The “default” option
under PPACA if
states do not opt for
SBE or SPE;
• 2013-14 grant funding
may be limited.
• Limits risk to the
state of eligibility
systems, call centers
and other functions
“not working.”
• 26 states including
TX, FL, GA and PA.
• Facilitating single
payor??????
15
CMS will train hospital ED
staff re: exchanges.
 CMS Acting Admin. Tavenner address to
Federation of American Hospitals—3/5/2013
DailyDose@ModernHealthcare.com
 CMS is planning to train Medicaid liaisons in
the “larger EDs” where applicable.
 FFEs will target “high risk areas” such as the
EDs for “navigator programs”—federally
funded educational liaisons to educate the
public re: exchanges.
16
The “essential health benefits” (EHBs) that
must be covered by “qualified health
plans” (QHPs) w/ coverage effective 1/1/14
1. Ambulatory patient services;
2. Emergency Services (recall the “Greatest of 3” discussion from
prior years);
3. Hospitalization;
4. Maternity and newborn care;
5. Mental health and substance abuse disorder services, including
behavioral health treatment;
6. Prescription drugs;
7. Rehabilitative and habilitative services and devices;
8. Laboratory services;
9. Preventive and wellness and chronic disease management; and
10.Pediatric services, including oral and vision care.
17
The Metal Levels that must be offered in
the HIE or may be purchased.
 Plans must offer a
Silver and Gold plan
in the HIEs.
 AV is the % of the
expected health
insurance costs that
a plan will cover.
 Silver level plans, for
example, offer
benefit coverage that
is the actuarial value
(AV) equivalent of
70% of the full AV of
the benefit package.
18
The Silver plan is likely to cover 70% of
the usual and customary charges for an
EHB.
 “Actuarial Value, or AV, is calculated as the
percentage of total average costs for covered
benefits that a plan will cover. For example, if
a plan has an AV of 70 percent, on average, a
consumer could expect to be responsible
generally for 30 percent of the costs of all
covered benefits in that plan.”
 http://cciio.cms.gov/resources/factsheets/ehb
-2-20-2013.html
19
How HIE subsidies work:
 Subsidies: Advanced payment of premium tax credits +
cost sharing subsidies paid directly to the health plans
by the exchange.
 Family purchase second lowest cost Silver plan then
their cost sharing is capped as % of income.
 If they purchase the Gold plan, family would pay the
difference.
 Families at or below 250% of FPL are subsidized for out
of pocket costs:
 Cost sharing cap of ½ of HSA limit between 200-250% of FPL.
 Cap of 1/3 of HSA limit under 200%.
 American Indians below 300% FPL have no cost sharing.
20
Kaiser Family Foundation (KFF)
Estimates of Patient Cost-Sharing Under
the Affordable Care Act (April ‘12)
 http://www.kff.org/healthreform/upload/8303.pdf
 KFF estimates the out of pocket limits (based on the HSA limits) to be
$6,350.
 Estimates
factor in cost sharing subsidies for FPL<250%.
Metal Level
Actuarial
Value
Deductible
Patient coinsurance
Est. out of
pocket limit
Bronze 1
60%
$4,375
20%
$6,350
Bronze 2
60%
$3,475
40%
$6,350
Silver 1
70%
$2,050
20%
$6,350
Silver 2
70%
$650
40%
$6,350
21
Individual or Family
Income as % of
FPL.
Families eligible for
subsidy.
Source:
NC IOM Report,
May 2012
Max. Premium for
2d lowest cost
Silver plan (% of
family income)
Out of Pocket
cost sharing
on average
(includes
deductibles
and coinsurance)
Out of Pocket cost
sharing limits
(Proportion of HSA Out
of pocket cost sharing
limits
Milliman’s NC
Population
Estimates (from the
NC IOM Report,
May 2012)
<133% FPL
2%
6%
$2,017 Individual;
$4,033** Family (1/3 of
HSA limits)
< 138% of FPL
Approx. 3%
133-150% FPL
3%--4%
6%
$2,017/$4,033
138-149% Approx.
5%
150-200% FPL
4%--6.3%
13%
$2,017/$4,033
150-199% Approx.
21%
200-250% FPL
6.3%--8.0%
27%
$3,025/$6,050 (1/2 of the
HSA limit)
200-299%, Approx.
30%
250-300% FPL
8.05%--9.5%
30%
$6,050/$12,100 (HSA
limit)
300-400% FPL
9.5%
30%
$6,050/$12,100 (HSA
limit)
300-400%, Approx.
16%
400% plus FPL
No limit
30%
$6,050/$12,100 (HSA
limit), **based on 2012
HSA dollar limits.
25%>400%
22
Case Study: NC Family
of 4 at 138% of FPL
138% of Federal Poverty Line = family
of 4 earning $31,809.
Family would pay about $80.00 per
month for Silver plan coverage.
Out of pocket limits would be $ 1909
per year (based on NC IOM estimate of
6% average cost sharing).
23
The “Crowd Out effect”: employer sponsored
insurance (ESI) will be replaced.
 Employees who earn up to 400 percent of
poverty – currently about $94,000 for a family
of four – are eligible to receive financial
subsidies to purchase coverage in the HIEs.
 Employers w/ 50 FTEs or more will pay the HIE
penalties and provide their employees w/ a
“401 k styled” match to purchase at least Silver
coverage. Source: Lewin Group Study, 2010.
 Impact: better commercial plans and rates may
be
as Crowd Out effect
24
What is going to happen with employer
sponsored health insurance (ESI)?
 Dr. Delos “Toby” Cosgrove, CEO of the Cleveland
Clinic, WSJ 12/19/12.
 “WSJ: do you think employers will stop providing
health insurance, even though they can pay a
penalty under the health overhaul law?”
 “Dr. Cosgrove: The first ones will be the small
companies….Every CEO I’ve talked to knows how
much he’d save between insuring his people and
paying the federal penalty.”
25
Summary: MCD Expansion,
Woodwork and HIEs.
 PPACA Positives for EM:
 Individual mandate drives Woodwork and the
exchange covered lives into health insurance.
 If no MCD expansion, 100-399% FPL come into the
HIEs w/ subsidized policies.
 State savings from MCD expansion.
 19: 1 ratio fed to state $ FMAP for expansion.
 MCD expansion has positive state gross domestic
product impact: $1.389 Billion between 2013-19 in
NC + MO study (appendix).
 92% of population=insured vs. 84% pre-ACA.
26
The Massachusetts
Experience
 Following global health coverage in Mass
 95% insured
 ED self pay population changed: 15% to 7%
 ED visits rose 9 percent
 Insurance didn’t equal access
 Robert Wood Johnson Foundation: Mass. ED
visits continued to increase in 2008 even for
non emergency care
 75.7% need for care after routine office hours
 55.8% inability to get an appointment
Summary: MCD Expansion,
Woodwork and HIEs.
 Negatives for EM:
 The Donut Hole remains uninsured: 5-8%.
 The “crowd out effect”: top rates could come down as
ESI is eliminated.
 Future FMAP funding of MCD expansion is X factor.
 DSH payments will be eliminated over time—potentially
disastrous for rural and community hospitals if they do
not receive MCD expansion.
MCD expansion could be worse for hospital based
providers vs. reimbursement in the HIEs.
 Primary care network adequacy & MCD reform are not
addressed.
28
Medicaid Eligibility Without Expansion
and with Health Insurance Exchange, e.g.
TX, GA, NC, WI and PA.
400%
350%
Exchange Coverage
300%
250%
Donut Hole
200%
Optional Coverage
150%
100%
Existing NCHC
50%
Existing Medicaid
Eligibles
0%
29
Remember what it looks
like in 2013—pre-ACA.
250
200
150
100
NC Health Choice
50
Medicaid
0
30
So, our theme for 2014
and beyond is …..
Up is the
New Up!!
31
“Hi Ho, Hi Ho It’s Almost Over the Cliff We
Go”: The American Taxpayer Relief Act
(ATRA) of 2012.
Highlights of the Doc Fix:
a. The Conversion Factor (CF) for 2013 is at $34.0230
(down $.0146 from 2012) until 12/31/13 (Section 601 (a)
(A)) of ATRA);
b.The Work-GPCI floor of 1.0 has been extended as well
until 12/31/13 (Section 602);
Both a. and b. above remove doubts about the CF for
2013 subject to the comments below regarding
“sequestration.”
32
The American Tax Relief Act (ATRA) of
2012 (cont.); a/k/a “the Doc Fix”, and the
2013 calendar:
 The -2% across the board reductions in
Medicare Parts A and B as part of the
“sequestration” scheduled for March 1, 2013
(Section 1001) were delayed by OMB until
4/1/13.
 April: budget bills due.
 May: 3-month debt ceiling deal expires.
 Focus will be on deficit reduction.
 Entitlement reform will be on the table.
33
According to the AMA:
Entitlement Reform & SGR
 CBO says repeal costs $250 to $300 billion.
 Only way to find that sort of money is in a bill
that makes other large scale changes.
 Congress wants assurances that physicians
are moving to more cost-effective payment
and delivery systems.
 AMA and 109 other medical societies signed a
set of principles for replacing the SGR and
moving into new delivery and payment
models.
34
2012 and 2013** ED RVUs
Code
RVU
Work
RVU
Prac.
Exp.
RVU
Liability
2012
Total
2013
Total
99281
0.45
0.12
0.03
0.60
0.60
99282
0.88
0.23
0.07
1.18
1.18
99283
1.34
0.32
0.10
1.77
1.76
99284
2.56
0.59
0.22
3.37
3.37
99285
3.80
0.83
0.30
4.94
4.93
99291
4.50
1.56
0.34
6.38
6.40
35
Future RVU Evolution:
 2012: RUC 5 year review
 33 E/M codes reviewed
 14
on average 18.7% (Observation winner)
 2013 ED RVUs stable
 GPCI floor of 1.0 in place for 2013
 Frontier Sates : NV, SD, ND, ID, WY, MN typically held
harmless
 Alaska permanent 1.5
 2017 next possible E/M 5 year work review
 No clear 9928x plans at this point
 CMS Practice Expense and Liability tweaked
annually
36
Conversion Factor:
What Medicare pays for 1 RVU
 Fairly tight range from 1998-2009
 1998--$36.6873
 2001--$38.2581
 2009--$36.0666
 2012--$34.0230
 Medicare Physician Fee Schedule 2013 Final Rule CF of: of
$25.0008 representing a 26.5% cut
 Congressional Action
 SGR Patch though 12.31.13 CF of $34.0230
 Sequester mandated 2% cut back in play for March
 Budget neutrality erosion with primary care redistribution
 Annual Wellness visits
 Post Discharge coordination of care new codes for 2013
37
Evolving RUC Issues.
Changing RUC member dynamics
Primary Care seat
Geriatrics seat
Long term viability of the RUC
 IBAP, MEDPAC
Response to Medicare data trends
38
EM has been in the news: NY Times, WSJ, 60
Minutes (all 2012) and now Time Magazine and the
Atlantic Monthly—with focus on the hospital facility
charges—but does the public see it that way?
 How Much Does It Cost to Go to the ER?
 By Lindsay Abrams
 “Treating a UTI costs $2,598, on average -- and we needed a
study to tell us this. ” (referencing the Time Magazine piece).
 “The average cost of a visit to the ER for over 8,000 patients
across the U.S. was $2,168. But the interquartile range (IQR),
which represents the difference between the 25th and 75th
percentile of charges, was $1,957 -- meaning many patients
were paying a lot more or a lot less than that. Of the top ten
most common reasons for ER visits, treating kidney stones
was most expensive, on average. But it was also the most
variable.”
 http://www.theatlantic.com/health/archive/2013/02/how-muchdoes-it-cost-to-go-to-the-er/273599/
39
 “All of the charges -- which represent the total bill for adults 18 to 64
years old who, for simplicity's sake, came in with a single outpatient
diagnosis -- followed similar patterns:
40
The “shift to the right”: per
the OIG, May 2012.
• Causes= paper to
templates to EMRs,
in urgent cares
/alternative care
settings and
Medicare/more acute
population.
• EDP’s 99285s
increased significantly
higher relative to office
and inpatient E/Ms
studied by OIG.
41
41
The Times story on 9/21/12 takes the
controversy re: EHRs to the next level w/
multiple ED references:
“Medicare Bills Rise as Records Turn
Electronic”
 http://www.nytimes.com/2012/09/22/business/medicarebilling-rises-at-hospitals-with-electronicrecords.html?pagewanted=all&_r=0
42
Cloning Under Scrutiny
“There are troubling indications that some providers
are using EHR technology to game the system, to
obtain payments to which they are not entitled. False
documentation is illegal. A patient’s information must
be verified by the provider to ensure accuracy and can
not simply be cut and pasted. Law enforcement will
take appropriate steps…” September 24, 2012
43
CMS Responds to the nat’l
debate.
CMS Manual System Pub 100-08 Medicare Program
Integrity
Transmittal 438 Effective date December 10,2012
 Purpose: “To define progress notes and Limited space
progress note templates”
 “CMS does not prohibit the use of templates to facilitate
record-keeping. “ However….
8033.3 Review contractors shall remember that progress
notes created with Limited Space Templates in the absence
of other acceptable medical record entries do NOT
constitute sufficient documentation of a face-to-face visit
and medical examination. Cc: CERT, Medicare RACs, ZPICS
44
CMS Transmittal
442: effective
1/8/13
 The new
requirements are
in red.
 Amendments,
Corrections and
delayed entries
for paper and
EHRs.
 Amendments
and delayed
entries must be
noted as such.
 Entries in the
margin are not
compliant.
45
PQRI now Physician Quality
Reporting System(PQRS):
 Requires 50% on 3 measures
 Transitioning to penalty phase
 2012-2014 0.5 % Bonus
 2015 penalty phase -1.5%
 PQRS Update with publication of Physician Final Rule
 ED Measures continue: ASA for AMI, EKG for Chest
Pain and Syncope, Some Pneumonia measures
 Retirement Issues:
 Pneumonia O2 saturation (#57) and mental status (#58)
 Pregnancy test for female abdominal patients (#253)
 Otitis externa pain assessment (#92)
46
ED Physician Quality
Measures




Aspirin at Arrival for AMI
Electrocardiogram Non-Traumatic Chest Pain
Electrocardiogram Performed for Syncope
Pneumonia Measures:
 Vital Signs for Community-Acquired Bacterial Pneumonia
 Empiric Antibiotic for Community-Acquired Bacterial
Pneumonia
 Retired
 Assessment of Oxygen Saturation for CommunityAcquired Bacterial Pneumonia
 Assessment of Mental Status for Community-Acquired
Bacterial Pneumonia
47
Value Based Payment
Modifier
 “The modifier will adjust your payments based on the quality and
cost of care physicians deliver. You'll start to see the program
develop in 2013. “
 2013 Final Rule:
 Initial focus on groups with 100 or more providers
 Satisfactorily report PQRS for 2013
2015 VBP will be
0.0% (held harmless)
 Fail to report PQRS your VBP will be as much as -1.0% plus an
additional -1.5% as a PQRS program specific penalty for a total
of -2.5%
 Must self nominate for GPRO…pick Administrative claims
Option…7.15-10.15
 Efficiency component as well- still evolving
 Option to elect “quality tiering calculation” with ~1% at risk
48
Interaction Between 2013 PQRS
and 2015 VBM:
Groups of physicians
with >100 eligible
professionals
nominate prior to
Oct 15, 2013
Self-nominate to elect
Administrative Claims
Reporting or PQRS
GPRO and report at
least one measure by
Oct 15, 2013
Failure to report at least
1 GPRO measure or to
elect Administrative
Claims Reporting for
the 2013 PQRS
reporting period
No Tiering
Tiering
Elect quality tiering:
Up/down adjustment
based on quality/cost
composite score
49
0.0% VBM
No Penalties in 2015
-1.0% VBM Penalty in
2015
-1.5% PQRS Penalty in
2015
-2.5% Total Penalties in
2015
PQRS Incentive for Groups >
100 at Individual Provider Level.
 If the provider group >100 (EDPs and NPPs),
selects the Administrative Claims Option, the
group will avoid PQRS and VBM penalties.
 But the PQRS Incentive is earned at the
individual provider level via claims based
reporting, registry or EHR.
 http://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/PQRS/AnalysisAndPayment.html.
50
Successful intervention
re: bundling edits on U/S
 Claimcheck/ClaimsXten bundling edit/denials of
CPT 93308 (echo) and CPT 76705 (limited
abdominal U/S)—a/k/a FAST exam.
 Attorneys funded by EMAF on behalf of ACEP
stated that the denial edits rationale were
inconsistent with CPT.
 Response letter (in appendix) agreed
immediately to remove the CPT 93308 edit and
to further consider the U/S issue.
51
Multiple Procedure Payment
Reduction (MPPR) Expansion
 Diagnostic Imaging
 Previously only the TC
(technical Component)
 Expanded to the Pro (Physician
Component)
 List of Services expanding
 Now applies at the TAX ID #
level
 Previously only at the NPI level
 Payment at 75% for second
study (Pro)
 Facility Component discounted
to 50%
52








CPT 76604 US chest
76700 US abd, complt.
76705 US abd, lmtd.
76770 US abd, back wall,
complt.
76775 US abd, back wall,
lmtd.
76831 Echo exam, uterus
76856 US, pelvic,
complete
76857 US, pelvic, limited
Same day admit and Discharge
Observation Codes now have Typical
Times (99234-99236)
 99234 Observation for the evaluation and treatment of a patient
including admission and discharge on the same date, which
requires these 3 key components:
 A detailed or comprehensive history;
 A detailed or comprehensive examination;
 Typically 40 minutes are spent at the bedside and on the
patient’s hospital floor or unit.
 99235 …Usually the problem(s) are of moderate severity. Typically
50 minutes are spent at the bedside and on the patient’s hospital
floor or unit.
 99236 …Usually the problem(s) are of high severity. Typically 55
minutes are spent…
53
The Future: ICD 10 Update
2014
Go Live Date 10.1.2014
Physician Documentation Issues
Laterality: right, left, bilateral
Phase of care: Initial, Subsequent,
Sequela
Anatomic specificity
Chart construct
Provider Education
54
Thank you and Q&A.
55
Contact Information and
Appendices:
Ed Gaines, JD, CCP
Chief Compliance Officer
Medical Management
Professionals, Inc.
egaines@cbizmmp.com
David McKenzie, CAE
ACEP
Reimbursement
Director
Dmckenzie@acep.org
877-271-2506
800.798.1822 #3233
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So what if
individuals
do not
purchase
health
insurance?
Enforcement
by the IRS.
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Appendix: How will the HIE
subsidies actually work?
Sliding Scale Premium Tax Credit and
Cost Sharing Reduction based on 2d
Lowest Cost Silver Plan
Source NC IOM Report May 2012, Table
2.1
Citations: PPACA Section 1312 (d), 1501
as amended by the HCERA, Section
1002.
 Milliman’s NC
Population
Estimates (from
NC IOM Report):
3% <138% of FPL
5%: 138-149%
21%: 150-199%
30%: 200-299%
16%: 300-400%
25%> 400%
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HIE decisions as of 2/15/13.
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CCIIO Fact Sheet, 2/20/13 re:
annual out of pocket cost sharing
limits not yet set for 2014.
“As stated in previous guidance, the health care law
directs that, starting in 2014, all types of health
insurance will include an annual limit on out-of-pocket
cost sharing for individuals and families. While not yet
set for 2014, the comparable limit this year is $6,250 for
self-only coverage. This protection will ensure that
Americans will no longer face medical bankruptcy even
when they have health insurance. Future rulemaking
and sub-regulatory guidance will be issued regarding
the application of this policy to the group market.”
http://cciio.cms.gov/resources/factsheets/ehb-2-202013.html
“The Numbers are the
Numbers”
62
2011 Medicare Part B National
Summary Data File for NonPhysician Practitioners (NPPs)
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CMS Transmittal 438 Introduces a new
concept: “Limited Space Templates” (Nov.
2012):
 Red is new material.
 Templates are ok, but . . .
 “Review contractors shall
remember that progress
notes created with Limited
Space Templates in the
absence of other acceptable
medical record entries do
NOT constitute sufficient
documentation of a face-toface visit and medical
examination.”
 http://www.cms.gov/Regulations
-andGuidance/Guidance/Transmittals
/Downloads/R438PI.pdf
64
64
The “35 Reasons” List: why an EDP’s coding
acuity could skew right or left.
65
Case study: Connolly RAC Region C
announces Complex Reviews of E/M
Office code CPT 99215.
 CPT 99215, Level V office code for established
patients beginning Sept. 2012.
http://www.connolly.com/healthcare/pages/
ApprovedIssues.aspx
 Extrapolation of findings from the probe sample
is authorized by CMS.
 AMA responds citing various concerns:
 Subjectivity of E/M coding.
 Concerns over extrapolation.
 Requests an E/M “one level difference” forgiveness.
66
66
AMA Responds to RAC Office E/M
complex review:
 “At a minimum, because of the subjective nature of E&M coding,
CMS should specifically exclude one-level code differences
between CPT code 99215 and CPT code 99214 from recoupment.”
AMA Letter to CMS Acting Administrator Tavenner, 9/11/12
(emphasis added)
 Medicare Modernization Act of 2003: extrapolation is not permitted
unless:
1. Determination of sustained or high error rate,
2. Educational corrective action by the MAC to the provider has
failed to correct the errors.
 http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/r114pi.pdf
67
67
New Codes for Coordination and
Transition of Care
 Coordination of complex care 99487 – 99489
 management and coordination for all medical conditions,
psychosocial needs activities of daily living
 typical patient multiple chronic illnesses placing the patient at
risk of death or decline.
 Transitional care management services 99495 – 99496
 Starts with date of discharge and continues for 29 days
 99495- communication 2 days; face to face within 14 calendar
days of DC
 99496- communication 2 days; face to face within 7 calendar
days of DC
 Not typically reportable by ED Physicians
69
The “Greatest of 3” Rules from
Section 1302 of PPACA
 Interim final regulations clarify that to make sure balance billing
isn’t used to circumvent the cost-sharing rules, the regulations
also require plans to pay a “reasonable amount” to out-ofnetwork providers of emergency services.
 The regulations specify a “reasonable amount” is the greatest
of:
1. The amount negotiated with in-network providers for the
services (if there is more than one negotiated amount for a
particular service, the median of these amounts).
2. The amount using the same method the plan generally uses
to determine payments for out-of-network services (such as
the usual, customary, and reasonable charges) but
substituting the in-network cost-sharing provisions for the
out-of-network cost-sharing provisions, or
3. The amount Medicare would pay for the emergency service.
 Options 1 and 2 can be arbitrary, proprietary and subject to
manipulation, would be difficult to enforce.
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So what are the benchmark
plans?
71
Federally Facilitated Exchanges
(FFEs)
The AZ& CA Benchmarked Plans:
Federal vs. AZ & CA state
benchmarked plans:
http://cciio.cms.gov/resources/files/large
st-smgroup-products-7-2-2012.pdf.PDF
72
Appendix: Links to CCIIO
exchange information & University
of MO study:
http://cciio.cms.gov/resources/files/guida
nce to_states_on_exchanges.html
University of Missouri School of Medicine
study on the economic impact of
Medicaid expansion:
http://www.mffh.org/mm/files/MUMedicaidExp
ansionReport.pdf
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