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Medicare Incentives and the RHC

Medicare Incentives and the RHC. Charles A. James, Jr. President and CEO North American Healthcare Management Services. Session Objectives. Learn the various Medicare incentive opportunities. Learn how each Medicare incentive is calculated and services on which they are based.

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Medicare Incentives and the RHC

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  1. Medicare Incentives and the RHC Charles A. James, Jr. President and CEO North American Healthcare Management Services www.northamericanhms.com 888.968.0076

  2. Session Objectives Learn the various Medicare incentive opportunities. Learn how each Medicare incentive is calculated and services on which they are based. Learn how each of the incentives relate to the Rural Health Clinic program. www.northamericanhms.com 888.968.0076

  3. Medicare Incentive Programs Electronic Health Record Incentives HPSA - Health Professional Shortage Incentive Primary Care Incentive (PCIP) Physician Quality Reporting (PQRI) eRx (e-prescribing) Incentive www.northamericanhms.com 888.968.0076

  4. American Recovery and Reinvestment Act (ARRA) Signed into law 2.17.2009. $767 billion in new spending and tax cuts. $17 billion for adopting ‘meaningful use’ of HIT in hospitals and physician practices. Stipulates Medicare and Medicaid payment incentives including EHR, Primary Care, and HPSA. www.northamericanhms.com 888.968.0076

  5. Medicare EHR Incentive -Eligible Professionals Doctors of medicine or osteopathy Doctors of dental surgery or dental medicine Doctors of podiatry Doctors of optometry Chiropractors www.northamericanhms.com 888.968.0076

  6. Medicare Incentive Payment Structure CMS will make Medicare Part B incentive payments to physicians who have demonstrated that they are "meaningful" EHR users. Eligible providers will be paid up to $44,000 for meaningful adoption. Payments will be based on an amount equal to 75 percent of allowable charges. www.northamericanhms.com 888.968.0076

  7. Medicare Incentive Amounts “An Introduction to the Medicare EHR Incentive Program for Eligible Professionals” Centers for Medicare and Medicaid Services www.northamericanhms.com 888.968.0076

  8. Medicare EHR Payment Limitations “An Introduction to the Medicare EHR Incentive Program for Eligible Professionals” Centers for Medicare and Medicaid Services www.northamericanhms.com 888.968.0076

  9. Medicare/Medicaid “An Introduction to the Medicare EHR Incentive Program for Eligible Professionals” Centers for Medicare and Medicaid Services www.northamericanhms.com 888.968.0076

  10. EHR Incentive and the RHC To maximize the Medicare EHR incentive, EPs must receive $24,000 or more in Fee Schedule payments annually. The Medicare incentive program does not recognize NP/PA or RHCs. Typically, the Medicaid incentive is most appropriate for RHCs. www.northamericanhms.com 888.968.0076

  11. HPSA Incentive The HPSA bonus is a 10 percent incentive payment to physicians who provide covered professional services in a geographic HPSA. The incentive is 10 percent of the amount paid, not the approved amount. Incentive eligibility is determined by the location where the service was actually performed. Despite where the physician’s office is located, the HPSA bonus is determined by where the physician treated the patient. www.northamericanhms.com 888.968.0076

  12. HPSA Incentive Payment The incentive is 10 percent of the amount paid, not the allowed amount. HPSA incentive checks are issued quarterly. If the physician provided HPSA eligible services from January – March, the incentive payment will be received in April. Incentive payments are taxable and will be reported to the Internal Revenue Service (IRS) through the IRS 1099 process. www.northamericanhms.com 888.968.0076

  13. HPSA Incentive • HPSA Incentive: 10% Medicare Payments • Must be located in Geographic HPSA • Should get these for hospital claims Both PCIP and HPSA are payable together. www.northamericanhms.com 888.968.0076

  14. HPSA Incentive RHC Ramifications Hospital payments should receive the HPSA bonus. An area which has RHCs does not necessarily qualify for the HPSA bonus. www.northamericanhms.com 888.968.0076

  15. Primary Care Incentive Beginning in CY 2011, primary care practitioners will be identified based on their primary specialty of enrollment in Medicare and percentage of allowed charges for primary care services that equals or exceeds the 60 percent threshold from Medicare claims data 2 years prior to the bonus payment year. A provision to accommodate newly enrolled Medicare providers will be released in 2011. www.northamericanhms.com 888.968.0076

  16. Primary Care Incentive Payments • Primary Care (PCIP): 10% Medicare Pmts • Eligible for Primary Care docs • FP/IM/Peds/Geriatric • 99201-99215; 99304-99340; 99341-99350 are: • At least 60% of all allowable Fee Schedule services. www.northamericanhms.com 888.968.0076

  17. PCIP Services Defined 99201 through 99215 for new and established patient office or other outpatient Evaluation and Management (E/M) visits; 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (e.g., boarding home), or custodial care E/M services; and domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services; 99341 through 99350 for new and established patient home E/M visits. www.northamericanhms.com 888.968.0076

  18. RHCs and PCIP 60% of the allowable codes must be paid on the Medicare Physician Fee Schedule (1500). MOST of the allowable CPT codes for PCIP will never be billed on a 1500. www.northamericanhms.com 888.968.0076

  19. PQRI Eligible professionals who satisfactorily report quality-measures data for services furnished during a Physician Quality Reporting System reporting period are eligible to earn an incentive payment equal to a percentage of the eligible professional's estimated total allowed charges for covered Medicare Part B Physician Fee Schedule (PFS) services provided during the reporting period. www.northamericanhms.com 888.968.0076

  20. But… Services payable under fee schedules or methodologies other than the PFS are not included in Physician Quality Reporting (for example, services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals [including method I critical access hospitals], rural health clinics, ambulance providers, and ambulatory surgery center facilities). http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Eligible_Professionals03-08-2011.pdf www.northamericanhms.com 888.968.0076

  21. E-Prescribing Incentive The program provides an incentive payment to practices with eligible professionals (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who successfully e-prescribe for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).  www.northamericanhms.com 888.968.0076

  22. E-Prescribing Beginning in 2012, the program also applies a payment adjustment to those eligible professionals who are not successful electronic prescribers on their Medicare Part B services. www.northamericanhms.com 888.968.0076

  23. E-Prescribing An eligible professional must have and use a qualified eRx system and report on his or her adoption and use of the eRx system. …the eligible professional must meet the criteria for a successful electronic prescriber specified by CMS for a particular reporting period. www.northamericanhms.com 888.968.0076

  24. E-Prescribing Finally, at least 10% of a successful electronic prescriber's Medicare Part B covered services must be made up of codes that appear in the denominator of the eRx measure.  www.northamericanhms.com 888.968.0076

  25. eRx Denominator Codes Patient visit during the reporting period (CPT or HCPCS): 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109 www.northamericanhms.com 888.968.0076

  26. Eligible but not able to participate: Services payable under fee schedules or methodologies other than the PFS are not included in Physician Quality Reporting (for example, services provided in federally qualified health centers, independent diagnostic testing facilities, independent laboratories, hospitals [including method I critical access hospitals], rural health clinics, ambulance providers, and ambulatory surgery center facilities). www.northamericanhms.com 888.968.0076

  27. Filing a Hardship • Many practices are erroneously having the payment reduction applied. • Contact the QualityNet Helpdesk QualityNet Help DeskMonday – Friday from 7 a.m. – 7 p.m. CT(866) 288-8912 qnetsupport@sdps.org https://www.qualitynet.org/portal/server.pt/community/communications_support_system/234 www.northamericanhms.com 888.968.0076

  28. Presentation Resources “An Introduction to the Medicare EHR Incentive Program for Eligible Professionals.” Centers for Medicare and Medicaid Services. https://www.cms.gov/Regulations-and Guidance/Legislation/EHRIncentivePrograms/downloads/Beginners_Guide.pdf eRx and PQRS Eligible Professionals http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/Eligible-Professionals.html www.northamericanhms.com 888.968.0076

  29. Presentation Resources Trailblazer’s Overview of 2012 Medicare Incentives http://www.trailblazerhealth.com/Education/Documents/WBT/Overviewofthe2012MedicareIncentivePrograms03-21-12.pdf www.northamericanhms.com 888.968.0076

  30. MLN Articles SE1107 - 2011 Electronic Prescribing (eRx) Incentive Program Update – Future Payment Adjustments MM6514 - Coding and Reporting Principles for the Physician Quality Reporting Initiative (PQRI) and the Electronic Prescribing (E-Prescribing) Incentive Programs. SE1206 - 2012 Electronic Prescribing (eRx) Incentive Program: Future Payment Adjustments www.northamericanhms.com 888.968.0076

  31. CMS and Medicare Resources CMS Rural Health Center – www.cms.gov/center/rural.asp Online Manuals - www.cms.gov/Manuals/IOM/list.asp?listpage=1 Trailblazer’s Rural Health Clinic Manual www.trailblazerhealth.com/Publications/Training%20Manual/rhcmanual.pdf Cahaba – www.cahabagba.com www.northamericanhms.com 888.968.0076

  32. More CMS Resources Medicare Claims Processing Manual – UB04 Completion www.cms.gov/manuals/downloads/clm104c25.pdf Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues www.cms.gov/manuals/downloads/clm104c09.pdf MedLearn Catalog www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf www.northamericanhms.com 888.968.0076

  33. Contact Information Charles A. James, Jr. North American Healthcare Management Services President and CEO 888.968.0076 cjamesjr@narhsinc.com www.northamericanhms.com www.northamericanhms.com 888.968.0076

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