Archive for category CMS
Provided by Barbara K. Tomar, ACEP’s Federal Affairs Director
The Medicare Access and CHIP Reauthorization Act (MACRA) Final Regulation was released Oct. 14. This rule – now designated by CMS as the “Quality Payment Program”- describes requirements for physicians to participate in the Merit-based Incentive Payment System (MIPS) and/or the Advanced Alternative Payment Models (Advanced APMs). Both begin January 1, 2017.
Former ACEP President Dr. Mike Gerardi appointed an APM Task Force that is developing some models that we hope will be reviewed and approved by CMS over the next year. Work of the Task Force was overseen this past year by Immediate Past President Dr. Jay Kaplan and current ACEP President Dr. Becky Parker has pledged to continue to support Task Force efforts.
It’s important to note that since few emergency physician groups have ever participated in various CMS bundled payment models/ACOs, etc. in the past, we expect most of the members to participate in MIPS for the next year or so.
We were pleasantly surprised in our early review of the 2,200-page rule, that CMS responded to ACEP’s comments on the timing and scope of some of the new programs.
Merit-based Incentive Payment System (MIPS):
- Reduces timeframe for reporting. Instead of reporting quality measures (much like PQRS) for a full calendar year starting in January, members can report for as little as 90 days of their choosing and avoid the 4% penalty in 2019. (Similar to PQRS, there will be a 2-year lag between data reporting imposition of bonus/penalty.)
- Doctors can report MIPS as individuals or through their groups. However, physicians must elect one or the other for all MIPS categories.
- Quality measures reporting reduced from 9 to 6. Either 6 measures or a specialty measure set can be selected, 1 of which must be an outcome measure; if no outcome measures are available, a high priority measure.
- Reporting thresholds reduced from 90% of patients (or 80% for claims reporting) to 50% in 2017.
- Encourages the use of QCDRs and electronic sources through preferential scoring.
- Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the (requested) reduction of the cost performance category weight to zero next year. CMS was going to weight ‘resource use’ at 10% – a nearly impossible measure for EM due to current cost attribution methodology.
- CMS working on patient condition and patient relationship codes to improve future cost attribution. (ACEP’s recent comment letter to CMS noted that none of the patient relationship codes fit EM practice so we will continue to work with CMS to change this).
- (Clinical) Improvement Activities reporting burden reduced. Highly-weighted activities (20 points) reduced from 3 to 2 and medium-weighted activities or some combination of both need to equal 40 points. (Use of QCDR is highly weighted).
- Allows 90-day reporting, also.
- Advancing Care Information (previously known as Meaningful Use) reporting reduced.
- EM has been exempt from reporting on EHR measures and may continue to be in spite of the burden placed by the hospitals.
- Also reduced to 90-day reporting for 2017-2018
Advanced Alternative Payment Models (APM):
- Reduces amount of losses that APMs must bear. CMS used the term “more than nominal risk” in the draft and proposed that qualified APMs pay of to 4% of Medicare spending. The final rule is based on physician/APM revenue which would be at risk for 5% of revenue losses instead.
- Expanded the definition to include practitioners other than physicians so that models can address quality and costs of non-physician services.
Physician-focused payment model Technical Advisory Committee (PTAC):
Note: This brief description of PTAC is included as background as no changes to its role were made in the final rule.
- MACRA created the PTAC (of outside experts) to assist physician groups who are creating APMs, providing a first line review of proposals to determine whether such proposed models meet the criteria established by the Secretary of HHS for PFPMs and offering some technical assistance. Based on its findings, PTAC can make recommendations to CMS as to whether the model should be refined, further studied, tested or implemented, but CMS makes the final decision through its own application process.
I don’t get it. I do not understand why the US government has decided to paint a target on the backs of physicians who, according to the AMA, provide more charity care than any other specialty, in a program that uses so-called hired gun auditors to recoup over-payments in Medicare’s fraud and abuse prevention strategy. These are physicians who give away, on average, more than $140,000 a year in unreimbursed services to the poor and uninsured (4-10 times more than any other specialty), and serve a larger proportion of Medicaid and under-insured patients than the vast majority of other physicians. These charitable physicians are willing to treat everyone, regardless of their insurance status or ability to pay, day or night, Sundays and holidays, whether the patients are upstanding citizens or the disheveled homeless. These docs provide care to everyone who asks to be treated or comes to their door, even if they are intoxicated to near stupor, or ranting obscenities, or smell like a garbage dump, or shed deadly viruses in an epidemic, or are soaked in toxic chemicals released in an accidental spill or a terrorist attack.
None of these physicians are engaged in a criminal enterprise to cheat Medicare and the tax payers out of millions of dollars for care they never provided, or using stolen or purchased patient IDs to submit fake claims, or billing for tests not performed, or charging for equipment they never ordered. In fact, these specialists work almost exclusively in hospitals that carefully screen their credentials, and in medical groups that have some of the most extensive claims coding and billing compliance programs in the health care industry. Nonetheless, the government has selected these physicians for auditing under the Medicare Recovery Audit Contract (RAC) program by focusing on the evaluation and management (E&M) CPT codes that are used almost exclusively in claims submitted to Medicare by these specialists. Other E&M and procedure codes are also being targeted for audits by these RACs, but these other codes are widely used by many other physician specialties.
There is no question that fraud and false claims are a serious problem for Medicare, and cost taxpayers hundreds of millions of dollars every year. For every $1 the government spends on these RACs, it gets back $40. I am all in favor of dealing a heavy blow to those who try to cheat the system, provided the adjudication process is fair and the focus is on activities that are clearly in violation of the rules. There are those who believe that hiring these private audit contractors on a contingency basis (based on the amount of overpayments they find) is like paying a bounty hunter to bring in a possible suspect dead or alive, especially since many claims that the RACs deem overpaid are frequently found to be ‘not guilty’ on appeal. The rules that are applied to these claims are, unfortunately, not always clear and concise: E&M coding in particular is about how sick the patient is, and how complicated or difficult the medical decisions are to make. In other words, medical coding is an art, not a science, and using an auditor that is financially incentivized to interpret these rules in the most aggressive way, with the threat of big penalties and forfeitures, is like writing a law that stiffs you with a big fine for ‘parking too close to a fire hydrant’ without specifying how close is too close, or paining the curb red.
I don’t doubt that a few of these ‘charitable physicians’ stretch the coding rules a bit, or even overcharge for their services. It happens, but it’s not the rule, by any means. I have talked to quite a few of these particular specialists who have experienced RAC audits. They usually consider themselves to be good at documenting their care, who employ careful and conscientious claims coders for their billing service. They come away from the RAC audit experience angry, frustrated, baffled, fearful, indignant, and depressed. These physicians don’t go out of their way to intentionally up-code their claims, or un-bundle them (charge separately for items that should be covered under a single charge), and they take pride in their willingness to treat patients few other physicians are willing to see, regardless of the patient’s ability to pay. They are all overworked, sometimes underpaid, subject to stress burnout, and challenged by a seemingly impossible mission; and they do this for over 130 million patients in the US every year. These docs just don’t understand why their government would go out of its way to paint a target on the backs of emergency physicians.
This post also appears in The Fickle Finger www.ficklefinger.net/blog/
In response to a suit by emergency physicians and hospitals in Washington State that led to a judicial injunction against the State’s plan to restrict Medicaid payment for ED visits, the State of Washington’s Health Care Authority has conspired with CMS to require emergency physicians to provide services to Medicaid enrollees for free. Emergency physicians are required by law (EMTALA) to provide medical screening services (and stabilizing care) to anyone who presents to an emergency department, and these physicians are subject to severe fines and penalties if they fail to provide these services.
CMS is well aware of this obligation, yet this agency has notified the State of Washington that the Medicaid program may ‘proceed under its existing authority to pay for only medically necessary Emergency Room visits’ based on a list of so-called ‘non-emergency diagnoses’ submitted on claims to the Medicaid program in that State (and presumably, other states that want to use the same process). Thus, the federal government is requiring emergency physicians to perform a medical screening evaluation (which can be as simple as a brief history and exam, or as complicated as a full and thorough evaluation to rule out subtle but potentially life threatening medical conditions), but is telling federally-funded state Medicaid programs that they need not pay the emergency physician for this service if it turns out the patient does not have a medical emergency, based on this list of final diagnoses. When a government mandates a service from private individuals, and refuses to pay for that service, this is tantamount an unconstitutional and illegal taking of services, and is surely a violation of the physician’s rights.
Curiously, CMS does not allow Medicaid Managed Care Plans in any state to use a list of final diagnoses to preclude payment to emergency physicians or hospitals for these screening and stabilization services. Many states explicitly require payment for medical screening services even when no medical emergency is detected. It is pretty clear that Washington State’s HCA is pushing back hard on emergency care providers for having the gall to use the courts to defy their authority. Resorting to this kind of abusive policy, knowing that it is likely to undermine the financial viability of the safety net and the ability of emergency care providers to meet the needs of all of Washington’s citizens, goes beyond the pale.
The list of so-called non-emergency diagnoses that WA HCA has come up with provides a clear indication of the extent to which this agency will go. This list includes such diagnoses as: hyposmolality (which can cause coma), hemopthalmos (hemorrhage in the eye), foreign body in the hand (often causes infection), multiple contusions (as in getting a beating), pregnancy, etc. Even if every single one of these diagnoses can be managed in a physician’s office, it is important to understand that to get to these diagnoses, it is often necessary to rule out other conditions that may look very similar, but are far more serious, even life-threatening. Performing a cursory medical screening exam in an ED is a prescription for a very expensive EMTALA violation, a hospital’s loss of the right to treat Medicare patients, and a malpractice suit that can end a career. Requiring emergency care providers to perform these evaluations on Medicaid enrollees, and then refusing to compensate them for the effort (and the risk), is just reprehensible.
This post was also published in The Fickle Finger (www.ficklefinger.net/blog/)
CMS Scam Alert
Officials at the Centers for Medicare & Medicaid Services (CMS) said recently that scam artists have been contacting physicians’ offices by fax, claiming to be a Medicare carrier or Medicare Administrative Contractor. The fax instructs office personnel to respond to a questionnaire and provide an account information update within 48 hours to prevent an interruption in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.
The CMS advises physicians who have received such a request to contact their Medicare contractor immediately. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website
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