Transcript CMS Update - Texas Hospital Association

CMS Update
Texas Rural Health Forum
September 14, 2011
CMS Initiatives
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Expanded Benefits and Incentive Payments
Fraud and Abuse
Value Based Purchasing and Partnership for Patients
DME Competitive Bid Expanded Areas Expected in
2013
ICD-10 and HIPAA Version 5010
Electronic Health Record Incentives,
e-Prescribing, and PQRI
Pre-Existing Condition Insurance Program
And others……
Preventive Services Changes Effective
1/1/2011
• Coverage of Annual Wellness Visit Providing a
Personalized Prevention Plan (initial and
subsequent visits)
• Elimination of Beneficiary Cost-Sharing for
Preventive Services for Annual Wellness Visit,
Initial Preventive Physical Exam (IPPE), and
other Medicare preventive services
recommended by USPSTF with a grade of A or B
Coinsurance and Deductible Waived
Beginning in 2011
• Annual Wellness Exam, IPPE, Abdominal Aortic
Aneurysm Ultrasound Screening, screening lab
tests for diabetes and cardiovascular disease,
PAP test, screening pelvic exam, screening
mammography, bone mass measurement, PSA
test, colorectal cancer screening (except
barium enema), HIV screening lab tests,
vaccine and administration for flu,
pneumococcal and hepatitis B, medical
nutrition therapy
Preventive Cost Sharing Still Applies
• Diabetes Self-Management Training (DSMT) –
coinsurance and deductible not waived
• Barium Enema as colorectal cancer screening
– coinsurance applies, deductible is waived
• Digital rectal exam as prostate cancer
screening – coinsurance and deductible apply
• Glaucoma screening for high risk patients –
coinsurance and deductible apply
PPACA Primary Care – Part B Claims
• 1/1/11 - 10% bonus for primary care
physicians, NPs, CNSs, PAs for whom primary
care services = at least 60% of allowed charges
in Part B in a prior period (first time will use CY
2009 PFS claims data processed through
6/30/10), paid quarterly for primary care
services furnished during that quarter
Paid in addition to usual 10% HPSA bonus
PPACA Surgical Incentive – Part B
Claims
• 1/1/11: 10% bonus to general surgeons when
furnishing a major surgery (10 or 90 day
global) in a geographic HPSA, paid quarterly
• Paid in addition to usual HPSA bonus payment
Patient Protection and Affordable
Care Act (PPACA)
• Changes timely filing deadline to one year,
beginning with services provided on or after
1/1/10,
Services provided from 10/1/09 to 12/31/09
must be filed by 12/31/10.
• Watch Medicare contractor listserv for earliest
news on other changes as they become known
The Medicare Challenge in Fighting Fraud
and Abuse
– Each working day, Medicare:
• Pays over 4.4 million claims
• To 1.5 million providers
• Worth $1.1 billion
– Each month, Medicare
• Receives almost 19,000 provider enrollment
applications
– Each year, Medicare:
• Pays over $430 billion
• For more than 45 million beneficiaries
New Screening and Enrollment Rule
CMS-6028-F
• Provider Screening (ACA § 6401(a))
– Levels of Screening by Categories of Providers:
• Limited – physicians, medical groups, clinics, hospitals
• Moderate – Physical therapists, CMHCs, outpatients rehabs,
ambulance providers, currently enrolled DMEPOS and home
health agencies
• High – Prospective (newly enrolling) home health agencies and
suppliers of DMEPOS; providers and suppliers who have been
reassigned due to a triggering event, such as:
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Excluded by the OIG
Subject to a payment suspension
Terminated by Medicaid
Subject to other final adverse actions
New Screening and Enrollment Rule
CMS-6028-F
Final Required Screening and Levels of Risk
TYPE OF SCREENING REQUIRED
Verification of any provider/supplier-specific
requirements established by Medicare
Conduct license verifications, including
licensure checks across States
Database Checks (to verify Social Security
Number (SSN), the National Provider
Identifier (NPI), licensure, an OIG exclusion,
taxpayer identification number, death of
individual practitioner, owner, authorized
official, delegated official, or supervising
physician )
Announced or Unannounced Site Visits
LIMITED
MODERATE
HIGH
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Criminal Background Check
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Fingerprinting
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New Screening and Enrollment Rule
CMS-6028-F
• Temporary Enrollment Moratorium may be
imposed for 6 month increments (ACA §
6401(a))
– Conditions for a temporary moratorium
• CMS data suggests trends associated with high risk of fraud, such
as highly disproportionate number of providers per beneficiary
• A State has imposed a moratorium in a particular geographic
area or on a particular provider/supplier type
• In consultation with the OIG or DOJ, or both
– The moratoria will be limited to:
• Newly enrolling providers
• The establishment of new practice locations, but not the change
of practice location
New Screening and Enrollment Rule
CMS-6028-F
• Suspension of payment based on a credible
allegation of fraud (ACA § 6402(h))
– Examples of a “credible allegation of fraud” include, but are not limited to:
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Fraud hotline complaints
Claims data mining
Patterns identified through provider audits
Civil false claims cases
Law enforcement investigations
– Credibility determined in consultation with the OIG
– Duration of suspension
• For each suspension, attestations would be required every
180 days from the HHS OIG that the payment suspension
should remain in place
• The suspension will end after 18 months unless OIG or DOJ
indicated an action was imminent
New Screening and Enrollment Rule
CMS-6028-F
• Termination of a Provider under Medicaid
and CHIP if terminated under Medicare (ACA
§ 6501)
– Providers who have been terminated under Medicare or another
State Medicaid program, or have had billing privileges revoked after
January 1, 2011 must be denied enrollment or terminated under
other State’s Medicaid program or CHIP
– Providers who have been terminated under a State Medicaid
program may be revoked by Medicare
Improved Beneficiary Communication
• Redesigned Medicare Summary Notices CMS is
redesigning the Medicare Summary Notices to make
them simpler to understand and spot fraud based on
beneficiary feedback
– CMS conducted open door forum with SMPs to
catalog beneficiaries common complaints with the
MSNs
– CMS is piloting new MSNs in beneficiary focus groups
throughout the winter and spring
– The redesigned MSN is targeted for circulation for
Winter 2011/2012
Improved Beneficiary Communication
CMS is implementing 1-800-Medicare changes to make
it easier for beneficiaries to identify and report fraud:
• Enhanced collection and analysis of fraud calls
• Interactive Voice Response allows beneficiaries to go on
MyMedicare.gov to listen to most recent claims
Accountability through communication:
Distribution of program guidance
• The Medicare self-referral disclosure protocol will
enable providers and suppliers to disclose and actual
or potential violation and will clarify (ACA § 6409):
– The person, official or office to whom the disclosure shall be
made
– Instructions on the implication of the protocol on corporate
integrity and compliance agreements
– The protocol is distinct from the advisory opinion process at
SSA § 1877(g)
Accountability through communication:
Distribution of program guidance
• The Medicare self-referral disclosure protocol cont.:
– The Secretary may reduce the amount owed after
consideration of the following factors:
• Nature and extent of improper practice
• Timeliness of self-disclosure
• Cooperation in providing additional information related to
disclosure
• Other factors the Secretary considers appropriate
Self-Disclosure Guidance
• Regulations, letters and protocol can be found
at
http://oig.hhs.gov/compliance/selfdisclosure-info/index.asp
New Enrollment Application Fee
• Does not apply to physicians, non-physician
practitioners, physician groups and non-physician
groups
• Does apply to providers that are filing 855A,B,S
- initially enrolling
- adding a practice location
- revalidating their enrollment
• Initially $505, increased annually by CPI unless
letter requesting hardship exception is approved
New Enrollment Application Fee
• Must be submitted with enrollment
application via Pay.Gov online
• If not submitted, contractor will notify that fee
is due in 30 days or deny application or revoke
billing privileges
• Contractor will not begin processing until fee
is paid or hardship request is approved
New Revalidation Requirement
• Before March 2013, Medicare contractors will
notify all Medicare providers and suppliers to
send in revalidation provider enrollment
information
• Letters will start soon on rolling basis
• Revalidations due within 60 days of the date
of the letter
• Medlearn Matters Article SE1126
New Revalidation Requirement
• Applies to all providers and suppliers who
enrolled in the Medicare program prior to
Friday, March 25, 2011
• Will be subject to new screening categories
based on risk
• Applicable providers will need to pay
enrollment fee for revalidating
Penalty for Failure to Respond to
Revalidation Request
• Providers who fail to respond to the CMS
Medicare contractor’s revalidation request
may have billing privileges revoked and may
be barred from re-enrolling in Medicare for
one year
Ordering/Referring Update
• CMS is delaying implementation of CR 6417 and
CR 6421 to give all physicians and practitioners
time to update their enrollment information in
PECOS. Applies to physicians, PA, NP, CNM, CNS,
CP and CSW.
Once implemented, Part B CMS 1500 claims for
services that were ordered/referred will need to
include ordering/referring NPI information. If the
ordering/referring physician is not in PECOS, the
claim will be rejected and later denied.
Ordering/Referring PECOS File
• www.cms.gov/MedicareProviderSupEnroll
• Over 800,000 names and NPIs on file in PECOS
of physicians and non-physician practitioners
eligible to order/refer
• Sorted in alpha order by last name, with NPI
Ordering/Referring for
RHC/FQHC/CAH Physicians
• Physicians/NPPs who never bill Medicare Part B
can still enroll for the sole purpose of ordering
or referring
• Paper form CMS-855I, complete only certain
sections, and attach a cover letter stating
provider is enrolling only to order and refer
services and will not be filing claims to the Part B
carrier
• Mail application to Part B MAC provider
enrollment address
• CMS IOM 100-08, Chapter 10, Section 11.11
Internet-Based PECOS Enrollment
• Available to Part B individuals, groups,
organizations and Part A providers
• https://pecos.cms.gov
• RHCs, FQHCs not allowed to use the Internetbased PECOS for RHC/FQHC applications
• All providers use paper 855 for filing changes of
ownership, acquisition, mergers, consolidations,
changes in tax ID, changes in legal business name
Enrolling New Hospital-Based RHCs
• Consider filing a provider-based attestation
with your 855A application for new hospitalbased RHCs, and furnish a copy to the
provider-based staff in the Dallas Regional
Office
More Information on Medicare
Enrollment
• Go to CMS website
www.cms.gov/MedicareProviderSupEnroll
• CMS Internet Only Manual 100-08, Chapter 10
• Federal Regulations 42 CFR 424.500
DME Competitive Bid – Round 2
• Currently only affects DFW area
• Round 2 areas in Texas, probably in 2013:
Austin – Round Rock
Beaumont – Port Arthur
El Paso
Houston – Sugar Land – Baytown
McAllen – Edinburg – Mission
San Antonio
HIPAA Version 5010 – New X12
Standards
• 1/1/11 External testing of Version 5010 began,
CMS accepting 5010 claims as well as 4010 claims
• 12/31/11 External testing of Version 5010 must
be complete to achieve Level II compliance (able
to send and receive compliant transactions)
• 1/1/12 All electronic claims must use Version
5010; Version 4010 will no longer be accepted
• http://www.cms.gov/Versions5010
andD0 (note the last is a zero)
ICD-10 Implementation
• 1/16/09 HIPAA Final Rule to adopt ICD-10-CM
and ICD-10-PCS by October 1, 2013 for all
covered entities (not just for Medicare)
• ICD-10 codes are longer, use more alpha
characters, will require system changes
• No delays
• No grace period
ICD-10 Implementation
• Partial Code Freeze – last regular, annual
updates on 10/1/11
• After 10/1/11, only limited updates to capture
new technology or new diseases
http://www.cms.gov/ICD10 for information
on educational resources, code tables and
descriptions, mappings, etc.
PS&R Reports via Internet
• Must establish an IACS account and be approved
for PS&R access
• IACS verification process includes the submission
of supporting documentation and may take
several weeks to complete the entire process, so
start in advance of when you need it for cost
report preparation
• CMS PS&R Redesign Web page has user manuals,
guides, etc. (link on TrailBlazer website, and CMS
website CR 6519)
Medicare Advantage Payment Guide
• CMS guidance to MA plans regarding original
Medicare payments to providers (for PFFS
plan payments and out-of-network provider
payments):
http://www.cms.gov/MedicareAdvtg
SpecRateStats/downloads/oon-payments.pdf
Medicare Electronic Health Records
Incentive
• Only physicians, subsection (d) hospitals and
CAHs can participate
• Must demonstrate Meaningful Use in Year 1 of
participation
• Last year a provider may initiate program is 2014
• Last year to register is 2016
• Payment reductions begin in 2015 for providers
that do not demonstrate Meaningful Use
Medicaid Electronic Health Records
Incentive
• 5 types of eligible professionals, acute care
hospitals (CAHs) and children’s hospitals may
participate
• Providers may adopt/implement/upgrade
certified electronic health record technology in
first year of participation
• Last year a provider may initiate program is 2016,
and last year to register is 2016
• No Medicaid payment reductions for providers
who do not demonstrate Meaningful Use
Texas Regional Extension Centers
Primary focus of RECs
Priority Primary Care providers
• Family medicine, Internal Medicine, OB/Gyn, Pediatrics
• Small practices – 10 or fewer
• Providers in outpatient public health clinics, FQHCs, rural,
and community health clinics
Secondary focus
• Specialists and providers in larger settings (REC services not
federally subsidized)
Texas Regional Extension Centers
•Physician centric. Governance is
physician led. There is a vigorous
outreach partnership with TMA – “To
physicians from physicians”
•Vendor neutral. RECs can facilitate
the physician decision with
information and insight. No
“preferred” vendors will be selected.
•Advocate. RECs will promote the
interests of primary care physicians
in pursuit of EHR meaningful use
with ONC, State agencies, EHR
vendors, payers, labs, and HIEs
North Texas REC
DFW Hospital Council-ERF
www.ntrec.org
Gulf Coast REC
UT HSC Houston
www.uthouston.edu/gcrec
Wendy Wacasey
[email protected]
Kim Dunn
[email protected]
Mike Alverson
[email protected]
Pamela Salyer
[email protected]
713-500-3654
469-648-5140
CentrEast REC
Texas A&M HSC
http://centreastrec.org
West Texas REC
Texas Tech University HSC
www.wtxhitrec.org
Teneka Duke
[email protected]
John Delaney
[email protected]
Kathy Mechler
[email protected]
Billy Philips
[email protected]
979-862-5001
806-743-7960
Contact your local Regional Extension Center
www.TXRECS.org
EHR Resources
• EHR Helpdesk 888-734-6433
• http://www.cms.gov/EHRIncentivePrograms
• Region VI contacts:
HITECH inquiry phone: 214-767-6441
HITECH email: [email protected]
Lead HITECH: Kathy Maris
eRx and PQRI
• PQRI is now PQRS
• PQRI and eRx help: QualityNet Help Desk
866-288-8912
[email protected]
• “PQRI and eRx Quick-Reference Support Guide
for Eligible Professionals” available on
http://www.cms.gov/ERxIncentive
• IACS Home http://www.cms.gov/IACS
CMS/HHS Rural Resources
• CMS Open Door Forum Calls:
http://www.cms.gov/OpenDoorForums for
information on signing up for Rural Open Door
listserv
• CMS Web site Rural Health Clinic Center
http://www.cms.gov/center/rural.asp
• HRSA Office of Rural Health Policy Rural Assistance
Center – one-stop shopping for all Department of
HHS rural info
http://raconline.org
CMS Rural Resources
• Medicare Learning Network:
http://www.cms.gov/MLNGenInfo
• Medlearn Matters Listserv:
https://list.nih.gov
• Sign up for your Medicare contractor’s listserv:
http://www.cms.gov/MLNProducts/
downloads/CallCenterTollNumDirectory.zip to
get web address of your contractor’s homepage
PCIP – Pre-Existing Condition Insurance Plan
• Section 1101 of the Affordable Care Act (ACA) requires
that HHS establish a “temporary high risk health
insurance pool program”
• Provides coverage for individuals with pre-existing
conditions until the Health Insurance Exchanges are
available in 2014
– Law required establishment within 90 days of
enactment
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Administration of PCIP Varies by State
Federally-administered PCIP
State-administered PCIP
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Eligibility for PCIP
A person applying for PCIP must:
• Reside within the service area of the PCIP;
• Be a U.S. citizen or reside in the U.S. legally;
• Have been without health coverage for a minimum
of 6 months before applying; and
• Have a pre-existing condition, as defined by the
PCIP and approved by HHS.
*Rate must equal at least 200% of corresponding PCIP rate. Permitted for select applicants.
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Pre-Existing Condition Requirement
• Each PCIP determines how applicants must satisfy its preexisting condition requirement.
• In federally-run PCIP, applicants must provide:
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a denial of coverage,
offer of coverage with an exclusionary rider,
offer of coverage at least twice as much as PCIP rate,* or
provider’s documentation of a current or prior condition.**
• In state-run PCIPs, documentation requirements vary.
*Applicable only for a child under age 19 or for a person who lives in Massachusetts or Vermont.
** Applicable only for a child under age 19
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Applying for PCIP Coverage
• Each PCIP establishes mechanisms for
enrollment, e.g. mailing or faxing a paper
application or completing an online form.
• In federally-run PCIP, people can apply for
coverage by:
– Mailing a paper application;
– Calling the call center to complete an application over the
phone; or
– Filing out an online application at www.pcip.gov.
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PCIP Offers Comprehensive Benefits…
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Care in medical offices for treatment of illness or injury
Emergency services
Inpatient and outpatient hospital services
Inpatient and outpatient mental health and substance abuse
services
Prescription drugs
Home health care and hospice services
Outpatient laboratory and diagnostic services
In- and out-of-network benefits
…and Important Features for Consumers
• First-dollar coverage for preventive care
• No lifetime maximum on the amount the plan pays for
enrollee’s care
• Benefits are available immediately when coverage begins,
even for pre-existing conditions
• The ability to receive benefits at any qualified provider
2011 Plan Options and Out-of-Pocket Costs
As in commercial coverage, PCIP enrollees pay monthly premiums and deductibles
for coverage
Beneficiary
Responsibilities
Monthly premium
Medical deductible
Drug deductible
Out-of-pocket limit
Federal Plans
Standard
Option
Extended
Option
HSA-eligible
Option
State Plans
$93 - $578
$125 - $778
$97 - $600
$69 - $1,806
$2,000
$1,000
$2,500
$0 - $5,000
$500
$250
Incl. in
medical
$100 - $500 or
incl.
$5,950
$5,950
$5,950
$5,950
NOTE: Above amounts represent in-network costs. More information on costs and benefits is
available at http://www.pcip.gov.
NOTE: All deductible and copayment amounts are for in-network benefits.
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What Enrollees Pay for Care
Beneficiary
Responsibilities
Standard
Option
Extended
Option
HSA-eligible
Option*
Inpatient and Outpatient
Hospital Services
20%
20%
20%
Emergency Services
20%
20%
20%
Lab and Diagnostic
Services
20%
20%
20%
Medical Coinsurance
20%
20%
20%
Office Visit Copay
$25**
$25**
$25
$4/$40/25%
$4/$30/25%
$4/$30/25%
Drug Copay
State Plans
Varies
NOTE: Above amounts represent costs for selected in-network services. More information on costs
and benefits is available at http://www.pcip.gov.
*With the exception of preventive care, the full deductible must be met prior to receipt of benefits, including prescription drugs.
**Services in a physician’s office are available at fixed copay, even if deductible is not met.
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Where Consumers Can Find More Information
• Consumers interested in applying to PCIP may visit
http://www.pcip.gov
– Under “Select Your State,” consumers should click their state of
residence on the map to find state-specific information
• Consumers may also request information by calling
1-866-717-5826 (TTY: 1-866-561-1604)
– The Call Center is open from M–F from 7am – 10pm CST
• Consumers with Questions or Concerns may contact CHAP at
1-855-TEX-CHAP (1-855-839-2427) or visit their website at
www.texashealthoptions.com
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Regulatory Changes
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Rural Health Clinic Regulation
Inpatient Prospective Payment Regulation
Physician Fee Schedule Regulation
Others?
QUESTIONS?
• Thank you for all you do to serve Medicare
and Medicaid beneficiaries in rural areas!
Becky Peal-Sconce
CMS Regional Rural Health Coordinator
Dallas, Texas
(214) 767-6444 direct or (214) 767-6441 office
[email protected]