Physician Reimbursement Systems

1. Physician Reimbursement Systems The Premier Source for Coding & Reimbursement Assistance 2635 Walnut St. Denver, CO 80205 800.972.9298 Fax 303.534.0577 www.prscoding.com 1

2. 2012 Update

3. 2012 Update • SGR and Conversion factor • Health Care Reform • ACO’s • Billing Oversight • eRx • EMR • PQRS • ICD-10

4. Sustainable Growth Rate What will happen? What if the cuts go through?

5. Sustainable Growth Rate No plan to address SGR after Jan 1. $300 billion additional debt to “cure” Republican Senator – no SGR cuts Med Pac - Cut Non-Primary Care Super-committee for budget savings failed to make recommendations on budget cuts or a solution to the SGR

6. Sustainable Growth Rate What will happen? A. Permanent fixed SGR–no cuts B. Kick the can down the road–no cuts C. No action–27% cut What if the cuts go through? A. Continue to see Medicare all patients B. Limit Medicare patients C. Stopped seeing Medicare patients D. Start driving a cab or look for other work

7. Sustainable Growth Rate Action Work through Thanksgiving Christmas holidays– vacation the 1st few weeks in January Prepare for cash delay Line of credit / Cash reserves Schedule changes Prepare for cut in Medicare payments Cut expenses Plan to live with less

8. Health Care Reform In progress • Cost containment • Medical necessity • Increased over-site • Anti-Fraud • Audits & Take-backs • Cut Fee for service payments • Private • Medicare 4

9. Health Care Reform In progress (con't) • Payment Reform • Value Based Purchasing • Shared risk payment plans • ACO’s • Co-ops • Bundled payments • Medical Home 4

10. Health Care Reform In progress (con't) • Private payer positioning • Data collection • PQRS, • Elect Rx, • Prepare for EMR Grants • Quality / Cost Efficiency • Transparency 4

11. Health Care Reform “Wildcard!” Shortage of Urologist • Location specific • ? Increased bargaining power • Early vs. later 4

12. Accountable Care Organizations

13. Accountable Care Organizations • Final rules–physician friendly • Not yet fully defined • Many are positioning • Can be many shapes and sizes

14. Accountable Care Organizations CO’s • Rationale: • US Healthcare is known for its fragmented payment and delivery systems • Fragmentation leads to waste, duplication and, ultimately, unnecessarily high costs • Fragmentation of care may also lead to higher occurrence of medical errors and poor clinical outcomes

15. Accountable Care Organizations ’s • Most patients have multiple doctors (recipe for frustration) - • Lost or unavailable medical charts • Duplicated medical procedures • Having to share information over and over with different doctors

16. Accountable Care Organizations ’s • What is an ACO? • network of Hospitals, MD’s and other providers that share responsibility for providing care to patients with original Medicare coverage (not Medicare Advantage private plan) • The ACO agrees to manage ALL the health care needs of a minimum of 5000 Medicare beneficiaries for at least 3 yrs • GOAL: Provide seamless, high quality care for Medicare beneficiaries

17. Accountable Care Organizations ACO’s • Who’s in charge? • Hospitals, Primary Care Providers and other physicians are in charge but Insurers may also play a role. • Humana, United Healthcare and Cigna have announced plans to form ACO’s for the private market

18. ACO’s final rule • Two types of Risk Models in setting up ACO • One-sided Risk Model: sharing of savings for the first 2yrs and sharing of savings + losses for the 3 yr • Two-sided Risk Model: sharing of savings + losses for 3 yrs. • No requirements to withhold shared savings payments to cover potential future losses • shared savings from 1st dollar

19. ACO’s final rule’s • The amount of “Shared Savings” is linked to performance on five key quality standards: • Patient/Caregiver experience of care • Care Coordination • Patient Safety • Preventive health • At-risk population/frail elderly health

20. ACO’s final rule (con’t) • 33 quality measures instead of 65 • Beneficiaries assigned through attribution methodology • Elimination of requirement for EMR use– • Rolling application process

21. ACO’s final rule (con’t) • Antitrust relief • eliminated the need for mandatory review • relief applies to independent contractors • Fraudwaiversforsomepatient inducement services

22. Billing Oversight

23. “Big brother is watching” Medicare Administrative Contractor (MAC) Zone Program Integrity Contractor (ZPIC) Recovery Audit Contractors (RAC) Office of Inspector General (OIG) Comprehensive Error Rate Testing (CERT) Quality Improvement Organization (QIO) HOW DO YOU RESPOND?

24. OIGworkplan for 2012 • Evaluation and Management Services: Potentially Inappropriate Payments • Evaluation and Management Services: Trends in Coding of Claims • Evaluation and Management Services Provided During Global Surgery Periods

25. OIGworkplan for 2012 • Physicians and Other Suppliers: High Cumulative Part B Payments (New) • Physician-Owned Distributors of Spinal Implants (New) • Physicians: Place-of-Service Errors • Physicians: Incident-To Services • (New) Physicians: Impact of Opting Out of Medicare (New)

26. OIGworkplan for 2012 • Ambulatory Surgical Centers: Payment System Ambulatory Surgical Centers : Safety and Quality of Surgery and Procedures (New) • Part B Imaging Services: Medicare Payments • Diagnostic Radiology: Excessive Payments • Laboratories: Trends in Laboratory Utilization

27. Fraud Alert • USA today • TrailBlazers • RAC’s

28. RAC Process • Targets listed on Website • Demand Letter sent from RAC notification of suspected violation • 40 days to appeal to the RAC • RAC can reverse decision • Recoupment begins on Day 41

29. Normal Appeal Process • Redetermination by an FI, carrier or MAC • Reconsideration by a QIC • Hearing by an Administrative Law Judge (ALJ) • Review by the Medicare Appeals Council within the Departmental Appeals Board, (hereinafter “the Appeals Council”) • Judicial review in U.S. District Court

30. Electronic Prescribing (eRx) Incentive Program

31. Electronic Prescribing (eRx) Incentive Program • Report eRx data by any one of the following methods: • Submit 25 Medicare Part B claims with code G8553 (in the numerator) and a standard service code (denominator) directly to CMS before December 31, 2011 • Data submitted to CMS via a qualified (EHR) • Data submitted to a qualified and CMS-vetted Registry

32. Electronic Prescribing (eRx) Incentive Program • Why do this? • Electronic prescribers (or Group Practices) will be awarded a 2% additional bonus over their actual claims payments • What if you don’t do this? • 2012: 1% penalty assessed (“payment adjustment”) • 2013: 1.5% • 2014: 2.0%

33. Electronic Prescribing (eRx) Incentive ProgramProgram • What constitutes a “Qualified”eRx system? The system must be capable of; • Generating active medication list • Selecting medications, printing prescriptions, eRx, and conducting alerts • Information related to lower cost and Rx alternatives • Provides information on formulary and authorization requirements

34. Question • Is your practice considering participating in the eRX incentive program? • A. Yes • B. No • C. I don’t know • D. I don’t think we will qualify

35. MedicareEHR Incentive Program

36. MedicareEHR Incentive Programr • Overview: • The Medicare/Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology

37. MeMedicareEHR Incentive Program • Eligible professionals can receive up to $44K over five yrs • To get max payment, participation must begin in 2012 • 2015 or later - Medicare eligible professionals that do not successfully demonstrate meaningful use will have a “payment adjustment” in Medicare reimbursements

38. Common barriers • High cost of implementation and maintenance • Uncertain of the return on investment • Providers incur the acquisition costs • plans receive the financial benefits • Challenges: • time/cost of personnel training • uneven financial rewards • equipment costs • “Meaningful use”

39. Question • Has your practice looked into the EHR incentive program? • A. Yes • B. No • C. I don’t know • D. Yes, but we don’t qualify

40. Physician QualityReporting System (PQRS)

41. Physician QualityReporting System (PQRS) • Financial incentive for eligible professionals to report data • The implication is that, in addition to reporting quality data, eligible professionals will also track and use quality data to make service and practice improvements which is the primary aim of PQRS.(and, save $$$)

42. Physician QualityReporting System (PQRSRS • Financial Incentives for participating professionals: • 2011: 1% of providers total allowed Medicare charges • 2011: an additional incentive of 0.5% by participating in a Maintenance of Certification Program • 2015: a 1.5% penalty may be applied for failure to satisfactorily report PQRS measures and 2.0% by 2016

43. Physician QualityReporting System (PQRS)S • What are the options for reporting compliance with these pre-determined quality measures? • To CMS on their Medicare Part B claims (with G 8553 code) • To CMS via a qualified EHR product • To a qualified PQRI Registry

44. Question • Does your practice participate in PQRS? • A. Yes, with claims based reporting • B. Yes, using the registry • C. No, but we plan to start in 2012 • D. No

45. PQRS (Formerly PQRI) • Continues incentive payment for participation through 2014 • 1.0% 2011 • .5% 2012-2014 • Beginning in 2015 a payment adjustment will be phased in over a 2 year period

46. PQRS (Formerly PQRI) • Two time frames per year through 2014 • January through December • June through December • Two ways to report • Claims based reporting • Registry based reporting

47. ICD-10

48. ICD-10 ImplementationOctober 1, 2013 Will it be implemented? Will it be delayed? What is your biggest concern: Cash flow? Extra work? Audits? Added expense

49. AMA Takes Stand Against ICD-10 Implementation (11/15/2011) ---------. The AMA House of Delegates voted to work vigorously to stop implementation of ICD-10 ----"The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care. At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records ----,” Peter W. Carmel, M.D., AMA president,

50. Wall Street Journal. Friday, October 28, 2011 As of 10:07 AM MDT