Chiropractors who are confused re when and how they can bill Medicare patients for their services would be well advised to read this recent Fact Sheet on the topic from CMS, which addresses of being non-par with Medicare and how to bill Medicare patients properly.
with Jean Acevedo, Guest Contributor
As premiums and deductibles rise and coverage shrinks, more and more patients have difficulty paying for their health care. You can provide financial relief to your patients if you wish, but you should only do so in accordance with a uniform hardship policy.
As a general rule, the practice should not routinely waive co-pays or deductibles, or offer discounts based on a patient’s statement that the patient is suffering from financial hardship. If the practice does routinely offer discounts or waivers of deductibles without properly investigating a patient’s financial wherewithal, the practice runs the risk of violating its payor contracts, being accused of committing insurance fraud, and/or paying an illegal kickback to induce patients to come to the practice. Some payor contracts require the practice to bill the payor the lowest rate that the practice bills any of its patients, a so-called “most favored nation provision.” Typical Medicare participation agreements are subject to this type of provision. If the practice waives deductibles or co-pays, then insurers often take the position that the amount being billed by the practice to the insurer ought to be reduced by the amount waived. In addition, a regulator could conceivably accuse the practice of waiving co-pays and deductibles as a means of inducing patients to seek treatment from the practice in violation of anti-kickback laws.Continue reading
On May 1st, CMS issued a letter to Medicare Advantage Organizations (MAOs) and others regarding the effect of the 2% reduction from sequestration. The letter contains very important information for providers, especially regarding their relationships with MAOs. Most importantly (for purposes of this short article) is the section entitled “Reducing Payments to Contracted Providers” which states (in essence) that MAOs are to follow the terms of their contracts for contracted providers. The trouble is that some MAOs are using the letter as a basis for an across the board 2% payment reduction! Most contracts don’t allow this. Even more egregious is the fact that some commercial payers are following suit! Providers faced with such reductions need to know their rights and need strong advocates to push back.
Has your practice implemented a compliance program or considered improving an existing one? Is it really necessary? Prior to the Patient Protection and Affordable Care Act (ACA), the necessity for physician practices to develop compliance plans was merely voluntary. However, the ACA will now require physician practices to have a fraud and abuse compliance plan in place as a condition of continuing to participate in Medicare or Medicaid programs. Because the government first published guidelines in the year 2000 for the voluntary use of compliance plans in physician practices and has subsequently enacted a mandate in the ACA for compliance plans, many physician practices are proactively implementing them. While this compliance plan mandate may be viewed by physicians as yet another administrative burden and expense to the practice, it can have many benefits as well. Implementing an effective compliance program can have the result of not only reducing liability risks, but can also allow a practice to reap monetary benefits. In fact, it could be more costly for the practice not to have one!Continue reading
Via CMS.gov
What?
The Physician Feedback/Value-Based Payment Modifier Program provides comparative performance information to physicians and medical practice groups, as part of Medicare’s efforts to improve the quality and efficiency of medical care. By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume.
The Program (which is specific to Fee-For-Service Medicare—not Medicare Advantage) contains two primary components:
Select “Value-based Payment Modifier” from the options on the left side of the page.
Why?
This program supports the transformation of Medicare from a passive payer to an active purchaser of higher quality, more efficient health care through the value-based purchasing (VBP) initiative. Physician feedback reporting was initiated under Section 131 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Affordable Care Act of 2010. The Affordable Care Act directed CMS to provide information to physicians and medical practice groups about the resources used and quality of care provided to their Medicare Fee-For-Service patients, including quantification and comparisons of patterns of resource use/cost among physicians and medical practice groups. Most resource use and quality information in the QRURs is displayed as relative comparisons of performance among similar physicians or groups. Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS). Both cost and quality data are to be included in calculating payments for physicians. By 2017, the Value-based Payment Modifier is to be applied to all physicians who bill Medicare for services provided under the physician fee schedule.
Via HCMA, SGR Advocacy Alert from the AMA – – – – The negotiations between Speaker Boehner and President Obama on the Lame Duck tax and deficit reduction package are at an impasse. There is a very real threat of the 26.5 percent Medicare physician payment cut taking effect on January 1, 2013, at least temporarily.
If Congress does adjourn without addressing the payment cut being induced by the sustainable growth rate (SGR) formula, the Administration announced today that the Centers for Medicare and Medicaid Services will follow normal claims processing procedures.
That is, claims will not be held and Medicare carriers will process payments for physician services provided after December 31 under the normal 14-day cycle required by law. Payment for these claims would be based on the new, lower fee schedule conversion factor of $25.0008, as opposed to the current rate of $34.0376.
At this time, it is impossible to predict whether the 112th Congress will find a way to pass a stop-gap measure before adjourning, how long such a measure would last, or how long payment cuts will be in effect before legislation can be passed after the 113th Congress convenes in January. It is highly unusual for a new Congress to enact significant legislation in the first month of its session, but the circumstances facing our nation today are far from typical.
It is inexcusable that Congress is once again putting the 47 million Medicare patients and the practices of physicians who provide them needed health care at significant risk. The Medicare program has become unreliable and its instability undermines efforts by physicians to implement new health care delivery models that stand to improve value for seniors and other beneficiaries through better care coordination, chronic disease management, and keeping patients healthy.
The AMA believes that the financial disruption this situation will cause for physicians and their practices is unacceptable, and we will continue to fervently convey this message in the strongest possible terms to Congress and the Administration, as we have for the past several weeks. Our patient and physician grassroots networks have been activated, and we are seeking your voices to tell Congress just how deeply its inaction will affect you.
Despite these efforts, at this time we feel compelled to advise physicians to start making plans for steps they can take to mitigate this disruption and meet their own financial obligations in January, in case the 26.5 percent cut actually takes effect. Given the potential impact on practice revenue in early January, physicians should be certain adequate arrangements are in place to sustain their practices. For those physicians who are forced into the untenable position of limiting their involvement with the Medicare program because it threatens the viability of their practices, we urge that patients be notified promptly so that they, too, can explore other options to seek health care and medical treatment.
Repost Via mondaq.com and Kristen A. Larremore & Sarah K. Baker — On November 1, 2012, the Centers for Medicare and Medicaid (“CMS”) issued three final rules, to be effective January 1, 2013, that implement a number of Medicare and Medicaid payment changes for 2013 and 2014.
The hospital outpatient prospective payment and ambulatory surgery center (“ASC”) final rule with comment period updates the payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments and ASCs. This final rule changes certain amounts and factors used to determine the payment rates for Medicare services paid under the Medicare hospital outpatient prospective payment system (“OPPS”) and the Medicare ASC payment system.
According to CMS estimates, payments to hospitals under the OPPS for 2013 will be approximately $48.1 billion (an increase of $4.6 billion compared to 2012) and payments to ASCs for 2013 will be approximately $4.07 billion.
OPPS payment rates are being increased for 2013 by an outpatient department fee schedule increase factor of 1.8 percent. Additionally, the final rule continues to implement the statutory 2.0 percent reduction in payments for hospitals failing to meet the hospital outpatient quality reporting requirements, by applying a reporting factor of 0.980 to the OPPS payments and copayments for all applicable services. The final rule further modifies OPPS payments by basing future determinations of relative payment weights on geometric mean costs rather than median costs (which has been utilized in determining OPPS payments since the inception of the OPPS).
Payment rates for ASCs are being increased for 2013 by 0.6 percent (less than the 1.3 percent update included in the proposed rule).
Additionally, this final rule updates and implements new requirements under the Hospital Outpatient Quality Reporting (“OQR”) Program, the ASC Quality Reporting (“ASCQR”) Program, and the Inpatient Rehabilitation Facility (“IRF”) Quality Reporting Program. The final rule also (1) continues the electronic reporting pilot for the Electronic Health Record (“EHR”) Incentive Program, as finalized for 2012 through 2013, and (2) revises the various regulations governing Quality Improvement Organizations (“QIOs”), including (a) granting QIOs the authority to send and receive secure transmissions of electronic versions of medical information, (b) providing more detailed and improved procedures for completing Medicare beneficiary complaint reviews and general quality-of-care reviews (including a new alternative dispute resolution process called “immediate advocacy”), (c) increasing information beneficiaries receive in response to QIO review activities, (d) conveying to beneficiaries the right to authorize the release of confidential information by QIOs, and (e) making other technical corrections.
In addition to the foregoing modifications and payment updates reflected in the final rule, the following briefly lists certain additional changes implemented therein:
The Medicaid final rule requires State Medicaid agencies to pay at least the Medicare rates in effect under the Medicare physician fee schedule rate in 2013 and 2014 or, if higher, the rate using the calendar year 2009 conversion factor for primary care services furnished by physicians practicing within the scope of practice of medicine or osteopathy with a specialty designation of family medicine, general internal medicine or pediatric medicine, or a subspecialty within those specialties (as recognized by the American Board of Medical Specialties, American Osteopathic Association, or the American Board of Physician Specialties). Physicians are required to self attest for purposes of inclusion as a “primary care physician” that they are either Board-certified in family medicine, general internal medicine, or pediatric medicine or a subspecialty related to those specialties; or that 60 percent of all Medicaid services billed by such physician or provided in a managed care environment are for the specified evaluation and management (“E&M”) and vaccine administration codes. This payment requirement applies to primary care services paid on a fee-for-service basis as well as those paid on a capitalized or other basis by Medicaid managed care plans.
However, the final rule also requires a 100 percent federal match for any increase in payment above the amounts due for such services under the applicable Medicaid State plan rate as of July 1, 2009, such that no additional costs accrue to states for payments above the rates in effect under the 2009 Medicaid State plan methodology. Accordingly, unless a state has reduced its Medicaid rates since 2009, it will be fully reimbursed by the federal government for any increased payments. In order to claim such enhanced federal match, states must be able to document the difference between the July 1, 2009, Medicaid rate and the applicable Medicare rate for specified providers that is claimable at the 100 percent matching rate. States are given flexibility in determining whether and how often to update rates to conform to changes in the Medicare Part B Fee Schedule, if the 2013 and 2014 rates are applicable, since such scheduled rates are subject to periodic adjustments or updates through the calendar year.
Primary care physicians are targeted by these payment changes in part due to their ability to perform the vital function of coordinating patient care, including specialty care, but also due to the need for a sufficient number of primary care physicians to be participating in the Medicaid program prior to the expansion of Medicaid eligibility in 2014. Primary care services are defined under the Patient Protection and Affordable Care Act (“ACA”) (Section 1902(jj)) to include certain specified procedure codes for E&M (codes 99201 through 99499, to the extent covered by the approved Medicaid State plan or included in a managed care contract) as well as certain vaccine administration codes. Additionally, the higher payment rates are applicable to services provided under the personal supervision of eligible physicians by all advanced practice clinicians. Physicians delivering primary care services in a Federally Qualified Health Center or Rural Health Clinic are not eligible for increased payments under this final rule due to the view that these physicians are already reimbursed at the appropriate rate under the Medicaid statute.
Additionally, the final rule updates the regional maximum fees that providers may charge for administration of pediatric vaccines to federally vaccine-eligible children under the Pediatric Immunization Distribution Program (more commonly known as the Vaccines for Children program) by adding 42 C.F.R. Part 441, Subpart L. Under this program, each state is required to establish a Vaccines for Children program under which certain specified groups of children are entitled to receive qualified pediatric immunizations without charge for the cost of the vaccine. This program permits providers to impose a fee for the administration of such a vaccine, as long as the fee does not exceed the costs of such administration, without permitting the provider the ability to deny administration of the vaccine due to the inability of the child’s parents or guardian to pay the administration fee.
The explicitly stated, expected, overall benefit from the Medicaid final rule is increased provider participation by primary care physicians, resulting in better access to primary and preventive health services by Medicaid beneficiaries. However, skeptics have questioned the ability of the final rule to generate such increased participation due to the fact that the increased rates are only in place for a 2-year period, 2013 and 2014. Currently under the final rule, states are required to collect and report data to CMS on the impact of the higher rates on physician participation. That data will assist Congress in determining whether or not to extend the provisions of the final rule beyond the end of 2014.
In conjunction with implementing the foregoing Medicaid payment increases, CMS also released a Medicare final rule with comment period that includes a statutorily required 26.5 percent across-the-board reduction to Medicare payment rates for more than 1 million physicians and non-physician practitioners under the Balanced Budget Act of 1997’s Sustainable Growth Rate (“SGR”) methodology. While Congress has overridden the required reduction every year since 2003, currently no such action has been taken.
Additionally, the Medicare final rule establishes payment rates for 2013 for the physician fee schedule, payments for Part B drugs, and other Medicare Part B payment policies to ensure that the payment system is updated to reflect changes in medical practice and in the relative value of services. It also includes a new policy to pay a patient’s physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled-nursing-facility stay. The changes in care coordination payment and other changes in the rule are expected to increase payment to family practitioners by 7 percent, and other primary care practitioners between 3 and 5 percent, if Congress averts the statutorily required reduction in Medicare’s physician fee schedule.
The Medicare final rule also includes the implementation of the physician value-based payment modifier under the ACA. Under the ACA, this new system is required to apply to all doctors by the start of 2017, and is one of the trickiest and most politically loaded parts of Medicare’s effort to shift away from paying for the volume of services and toward the quality of care.
The value-based payment modifier is the percentage by which amounts paid to a physician group under the Medicare physician fee schedule are adjusted based upon a comparison of the quality of care furnished to cost of care. The payment modifier provides for differential payment starting in 2015, based on performance in the 2013 calendar year. CMS originally planned to apply the modifier to medical groups of 25 or more professionals; however, in the final rule CMS changed the plan to only include medical groups of 100 or more practitioners. This change was adopted to gain experience with the methodology and approach before expanding to smaller groups—which CMS emphasizes will occur in future rulemaking.
In general, physicians with higher quality and lower costs will be paid more, and those with lower quality and higher costs will be paid less. The final rule provides an option for these groups of physicians to choose how the value modifier is calculated based on whether they participate in the Physician Quality Reporting System (“PQRS”). The PQRS is a voluntary program that allows physicians and other healthcare professionals to report information to Medicare about the quality of care they provide to people with Medicare who have certain medical conditions. All of the quality measures for which groups of physicians are eligible to report under the PQRS starting in 2013 are used to calculate the value-based payment modifier to the extent the group submits such data. Note, however, that the final rule also makes minor changes to the PQRS. Additional quality measures for those not participating in the PQRS are composites of rates of potentially preventable hospital admissions or readmissions.
Among other changes, the final rule also implements provisions of the ACA by removing certain regulations regarding termination of non-random prepayment review. Medical review is the process performed by Medicare contractors to ensure that billed items or services are covered and are reasonable and necessary. As a result of this final rule, contractors are not required to terminate non-random prepayment medical review by a prescribed time, but instead must terminate each medical review when the provider or supplier has met all Medicare billing requirements as evidenced by an acceptable error rate as determined by the contractor.
Finally, the rule implements provisions of the ACA by establishing a face-to-face encounter with a beneficiary as a condition of payment for certain durable medical equipment items such as prosthetic devices, orthotics, and prosthetics. The encounter must occur during the six months prior to the written order for each item or during such reasonable timeframe as provided by the Secretary.
Overall, this Medicare final rule continues efforts by CMS to align quality reporting across programs to reduce burden and complexity, and emphasizes paying for the quality of care as opposed to volume of services provided.
Via Marilyn Tavenner, Acting Administrator, Center for Medicare Services 
It’s picking season – pumpkins, apples, Halloween candy…and a Medicare health or drug plan. Today is the start of Medicare Open Enrollment!
In my work with Medicare, one of the questions people ask me often is which plan is the best one. That’s not something I can answer, because picking a plan is an important and personal decision. Each person has a unique set of priorities. How do you weigh your options? Now’s the time to think about what matters to you, and pick the Medicare plan that meets your needs.
When you sit down to review your Medicare health and drug plan choices this year, keep track of the things you may want in a plan, and pick one that’s right for you. Here are some things to keep in mind while you consider your choices:
Costs
You should look at your current health care costs to find coverage that works with your financial situation. How much are your premiums and deductibles? How much do you pay for hospital stays and doctor visits? Just like with everything else, the lowest-premium health plan option might not be the best choice for you.
Coverage
Are the services you need covered? We know future health care needs can be hard to predict, but changes happen. Maybe your doctor changed your prescriptions this year or you have different health concerns. Make sure you understand what services and benefits you’re likely to use in the coming year and find coverage that meets your needs.
Convenience
Your time is valuable. When comparing plans, make sure you check which doctors and hospitals you’ll be able to use. Where are they located and what are their hours? Check which pharmacies you can use. Can you get prescriptions by mail? Remember that even if you’re happy with your current plan, these answers might change from year to year.
Quality of care
Ask yourself whether you’re truly satisfied with your medical care. Not all health care is created equal, and the doctors, hospitals and facilities you choose can impact your health. Look for plans with a 5‑star performance rating — the right expertise and care may help speed your recovery and improve your outcomes.
It’s worth your time to take a look and compare coverage between now and when Open Enrollment ends on December 7. Use the Medicare Plan Finder to look at all of the health and drug plan options in your area. If you still need help comparing, call 1‑800‑MEDICARE (1‑800‑633‑4227).
Only you know what’s most important to you and your family – that’s why I want to make sure you have all the information you need to make the best decision. Before you consider your Medicare plan options, think about your personal priorities so you can be sure your plan meets your unique needs.
Stay up to date on the latest Medicare news and follow us on Twitter @Medicarego
With special thanks to Dr. Brent Schillinger
The open enrollment period for Medicare Advantage plans runs from October 15 through December 7, 2012. That is precisely the reason why every form of communication—– be it internet, television, radio or your mailbox is loaded with recruitment messages from the big and not so big companies. Medicare Advantage Plans is the contemporary name given to the old Medicare HMO insurance programs. The difference is that today the marketing is particularly intense and slick because under current federal legislation, passed several presidential administrations back, the profits for the commercial insurers is huge. When the first Medicare HMOs appeared on the scene, they were providing care to seniors at an average cost savings (to the federal Medicare budget) of 5% less than traditional Medicare. Today, they provide care at upwards of 115% of the average cost per patient per year for traditional Medicare.
The plans market themselves to seniors offering more services for less money than a person would have to pay under traditional Medicare. In most cases there are savings in terms of reduced monthly out of pocket costs. And there may be extra services I such as a gym membership or a low-priced pair of eyeglasses. But there are many tradeoffs for patients tradeoffs that are not referenced in the marketing material. Patients are limited to doctors who are specifically contracted with the plan, specialist referrals are generally rationed, and it may be difficult, should a person desire care in a specific hospital if that facility is not contracted.
Seniors have options. They can choose from many different Medicare Advantage Plans and probably save some money, but they need to understand that they are giving up many of the choices they have with the other option, keeping traditional Medicare and adding supplemental medical and pharmaceutical insurance. Identified problems include:
Physicians will be approached by patients about the confusion in the choice of the Medicare Advantage plans vs. traditional Medicare. As your patients’ advocate you should become knowledgeable about the different plans so you can give reasonable guidance to your patients. This would also be a good time to review your contracts and reimbursement schedules as well the ability to obtain authorizations for prescription drugs and specialist referrals.
From an economic point of view, most physicians, in our area who participate in these Medicare Advantage plans receive reimbursements that are substantially lower than traditional Medicare. Take the United Health Care product for example. While United is paid by the government upwards of 115% of the average traditional Medicare cost, many specialists receive less than 70% of the normal Medicare allowable. Some of the Blue Cross plans work with a number of tightly restricted capitated networks so patients may not be able to see the doctor of their choice, individual physicians may not be able to join these restricted networks, and the same time the reimbursements through the capitated networks are pathetically low, often less than half of the traditional Medicare allowable.
Doctors need to take all of these factors into consideration in order to give their patients good advice. For additional information and patient resources you can visit www.pbcms.org or email Dr. Schillinger at [email protected].
Followers & Friends – BIG Announcement coming out today! If you haven’t seen our new NATIONAL platform, check it out here at www.nationalhealthcarelawfirm.com and stay tuned for our #healthcare #legal news at 2pm EST !!!
