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Preparing for 2011 – Where are we and where are we going

Preparing for 2011 – Where are we and where are we going. Cathie Biga President/CEO Cardiovascular Management of Illinois. Agenda. 2010 in review Technical Correction 2011 Physician Fee Schedule 2011 HOPPS Private Payers in 2011 HCR/ACA – its impact Core 2011 concepts: PQRS/eRx….

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Preparing for 2011 – Where are we and where are we going

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  1. Preparing for 2011 –Where are we and where are we going Cathie Biga President/CEO Cardiovascular Management of Illinois

  2. Agenda • 2010 in review • Technical Correction • 2011 Physician Fee Schedule • 2011 HOPPS • Private Payers in 2011 • HCR/ACA – its impact • Core 2011 concepts: PQRS/eRx….

  3. Legal Primary Issues • HCR/ACA • Threats to physician ownership/in-office imaging • SGR – will it ever be fixed • IPAB • CMI Secondary Issues • Key topics – 1) Disclosure requirements for CT, PET, MRI, 2) PECOS, 3) POS/DOS, 4) Timely filing • 2012 Accreditation of labs and 2010 IAC changes • Meaningful use – stretch or a barrier?

  4. Regulatory • PFS 2011 • 2nd year of PPIS implementation • Bundling continues • Rebase for MEI • RUC focus • HOPPS 2011 • Reductions beginning? • Quality focus continues to grow • Ongoing scrutiny of imaging and IOE • EP becomes its own specialty 4/4/11 • ENROLLMENT NEEDED

  5. Economic • Gap in technical • Bundling of nucs ’10 • Bundling of caths ’11 • Massive PV bundling • RAC’s, MACs, and other attacks • Revenue wherever you can find it • Clinical integration • PQRI • eRx • Meaningful use • Operational efficiencies • New product lines

  6. Technical Correction What is it What do we do What have people done Current status

  7. What is the real story In May of 2010 the updated files also contained updates to RVU units. This has a range of .60 refunds to $50 –$60 increases for some services

  8. Refund Request

  9. Technical Correction • $2M just appropriated for re-filing • How to handle both the upside….and the downside • Patient responsibility • Secondary's • You have to love it…

  10. 2011 Fee Schedule • Be sure you have downloaded the one with the $33.97 CF • Let’s walk through the key elements and lo lights

  11. {(RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)} conversion factor x BN X Medicare formula Resource Based Relative Value Scale Payment = RVU = Relative Value Unit GPCI = Geographic Practice Cost Indices

  12. SGR….. SGR …. Rollercoaster throughout 2011 13 month “fix” That only cost $19 BILLION No increase for physicians After the May technical correction the CF was $36.8729 Sunset – Dec 1, 2010 (was to be a 23.6% hit) Sunset – Jan. 1, 2011 – 12 month extension 2011: Conversion Factor = $33.9764

  13. MEI …impact CMS is rebasing and revising the MEI to use a 2006 base year in place of a 2000 base year. This update to the MEI is the first time it has been rebased and revised since 2004. For practices with high technical this will result in an increase Total RVU’s attributed to work will see a decrease Bottom line – mitigated a bit of the PPIS hit Resulted in a major CF change

  14. Why do my fees keep changing RVU changes This is the last year of a 4 yr phase in on how PE are determined – we are DONE with this This is the 2nd yr (of a 4 yr plan) due to the PPIS This is the 1st time MEI has been re-based The RUC keeps messing with us Bundling Revaluing

  15. Other key factors of2011 Fee schedule Financial Disclosure letter and sites MRI, CT, PET Time of referral 5 suppliers within 25 miles Document compliance EU rate – 75% Multiple procedure reduction Affects technical component 25% increases to 50%

  16. MEI…PPIS…CF….Just tell me what it means

  17. Treadmill

  18. Hopps Echo payment reduced – 13.5% PET reduced Supervision re-defined Hospital outpt on campus Hospital outpt off campus

  19. HOPPS changes

  20. Private payor shenanigans Highmark….. Substitute echo for nuc United pre-notification Humana pre-notification Report cards

  21. HCR aka ACA • Grandfathered and non-grandfathered plans • Coverage • Lifetime limits • Equipment Utilization: The ACA overrules the fee schedule and will lock this rate at 75% • House energy and commerce – J.Pitts • my first legislative priority will be wholesale repeal of the health law, which will pass the House, I'm sure, but realistically won't get past the Senate or the president. • ACA law requires that PCMHs be exclusively primary physician based, how do we ensure specialty based PCMH models can be authorized

  22. Integration • Drivers • HCR • MedPac and imaging scrutiny • Payment reform mandates • HOPPS vs PFS • Is it here to stay?????

  23. ACC’s survey

  24. Integrate with hospital….OrOther practices

  25. Integrated Practices

  26. ACO’s….. Rules due out in Jan ACA attributes patients to ACOs (by virtue of the doctors and hospitals they currently use) ---patients do not enroll in them. This is confusing, because if patients do not want to be in an ACO and instead stay with their doctor who chooses not to participate, they may. But if their doctor is in, so is the patient. This issue may need to be amended somehow

  27. AUC…..where is it going Midei case in Baltimore ACE from SCAI (accreditation for cardiovascular excellence) JAMA article on ICD FOCUS – nuclear Lab accreditation MIPPA IAC – focus on use of AUC

  28. Quality …where is it going? Recent CMS report 3 demo projects Hospital Quality Incentive Demonstration (HQID) the Physician Group Practice (PGP) 500 small and solo physicianpractices participating in the Medicare Care Management Performance (MCMP http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp.

  29. Physician Compare Public reporting of data Starts 1/1/13 Mandated by ACA Physicians need to be able to update their contact info Comment period is now

  30. Few more…. Sunshine Act 2012 Anything over $10 will be reported PECOS CMS is working “diligently” Edit not turned on for referring MD NO DATE has been announced Red Flag – finally gone

  31. What is this “new” MOC MOC = Maintenance of certification Additional .5% in PQRS payments if enrolled in MOC Must submit PQRS data for 12 months, participate in MOC, and complete MOC practice assessment FOCUS and CPIP

  32. PQRS aka PQRI PVRP was initial program in 2006 PQRI - 7/1/07 – 1.5% incentive payment 2008 – Few structural changes 2009 and 2010 - 2% incentive payment Yes you can do this + Meaningful use 2011 – Physician Quality Reporting System 194 measures

  33. PQRS Resources A Guide for Understanding the 2011 Physician Quality Reporting System (PQRS) Incentive Payment www.cms.gov/pqrs https://www.cms.gov/PQRI/15_MeasuresCodes.asp#TopOfPage http://www.cms.hhs.gov/MedicareProviderSupEnroll http://www.cms.hhs.gov/IACS https://www.cms.gov/PQRI/30_EducationalResources.asp#TopOfPage

  34. Key Changes Penalties start in 2015 2011 – 1% payment 2012 – 2014 - 0.5% payment Reporting sample reduced from 80% to 50% for claims ONLY Registry still must meet 80% on 3 measures Registries no longer can report on non-Medicare FFS Measures with 0% will not be counted New group reporting option <200 26 measures

  35. Changes to Structure and Function In response to ACA Penalty: 1.5% in 2015 & 2.0% after Timely feedback Interim reports Informal appeal process Physician Compare Website Reports 2012 PQRS Integration with MU

  36. Measures 170 measures continue (24 new) 45 registry measures continue 11 new registry only 14 Measure Groups EHR current 10 + 10 new

  37. No Changes #6 – CAD on Antiplatelet #7 – CAD prior MI on BB #47 – Advance Care Plan #124 – Use of EMR #201 - IVD & BP Control #202 - IVD & Lipid Profile #203 – IVD & LDL New #128 – BMI Screening & Follow Up #226 –Tobacco Screening & Cessation #235 – HTN Plan of Care Changes #5 – HF on ACE/ARB #8 – HF on BB (remove Cardiomyopathy codes) #114 – Smoking Screening #115 – Smoking Cessation (retired) #118 – CAD on ACE/ARB & DM and/or LVSD (remove Pregnancy Diabetes codes) PQRI 2011

  38. Summary 2011 changes

  39. eRx for 2011 Can NOT do in addition to MU You can do eRx + PQRI 1% Incentive payment Need to do 25 instances 2011 report for entire year Penalties start in 2012 BUT

  40. ****IMPORTANT**** See pgs 1305 to 1307 MUST have an approved system 10 instances per provider from Jan1 – June 30, 2011 Must do even with MU Must do via CLAIMS Submit the G code to prevent penalty Not only does 2011eRx determine 2012...but  it also locks you in for the penalty!

  41. THE Penalty You can NOT use EHR or registries to submit Yes you can receive incentive money……..and still be penalized Penalties will be NPI specific CMS needs info by 12/21/11 Are they reaching beyond their legal scope?

  42. Note the 2013 penalty

  43. Are there any exceptions… Provider does not have at least 100 cases containing an encounter code in the measure denominator Provider does not meet the 10% denominator threshold For the 2012 eRx payment adjustment, the following circumstances would constitute a hardship: The eligible professional practices in rural area with limited high-speed internet access, or The eligible professional practices in an area with limited available pharmacies for electronic prescribing G-codes have been created to address two hardship circumstances (G8642 and G8643) To request a hardship exemption for 2012 payment adjustment: An eligible professional must report the appropriate G-code on at least 1 claim prior to June 30, 2011

  44. eRx Incentive 2011 Attached to an E&M code Use Code G8553 Must submit 25 eRx Medicare patients to get 1% incentive Reported on claims or Registry eRx Penalty 2012 & 2013 Attached to an E&M code Use Code G8553 Must submit 10 eRx Medicare patients between January and June 30, 2011 to avoid 1% adjustment in 2012 Report on Claims only Must submit 25 eRx Medicare patients between January and December 31, 2011 to avoid 1.5% adjustment in 2013 Report on Claims or Registry eRx Meaningful Use Does not tie to an E&M code Doesn’t use G codes Must have more than 40% of all permissible prescriptions transmitted electronically Tracks faxed, printed or e-prescribed prescriptions Excludes Controlled Substances Applies to all patients, not specific to Medicare eRx Comparison

  45. Qualified eRx system is… Must do ALL of the following Generate an Active medication list Incorporates e data from pharmacies and pharmacy benefit managers Select meds, print prescriptions, transfer electronically, and conduct ALL alerts: Provide info on lower cost alternatives Tiered formulary info is sufficient in 2010 Provide info on formulary or tiered formulary medications, pt. eligibility, and authorization requirements received electronically from pt’s drug plan

  46. Lessons learned Remember the 10% rule Don’t forget mid levels How penalty will be applied… www.cms.gov/erxincentive

  47. Is it worth it??? • Clinical Integration $134,940 • Clinical Integration $272,114 • PQRI @ 2% $219,175 • PQRI @ 2% $167,915 • eRx @ 2% $174,473 • eRx @ 2% $168,652 $1,137,269 Personally I think that is REAL money

  48. Meaningful Use 25 Objectives and Measures 15 Core Mandatory Measures 10 Menu Measures (Must meet 5 out of 10) 6 Total Clinical Quality Measures 3 Core 3 out of 38 from Menu set Reporting 8 Measures reported through Attestation 1 Measure reported with Numerator and Denominator and Exclusion through Attestation (Clinical Quality Measures) 16 Measures reported through Numerator and Denominator Reporting Period First year of demonstration: Any continuous 90-day period within the payment yearin which you successfully demonstrate Meaningful Use Second payment year and beyond: The EHR reporting period will mean the entire payment year

  49. Meaningful Use = Core Measures • CPOE = 30% • Drug-Drug and Drug-Allergy Interaction Checks • Up-to-Date Active Diagnoses List = 80% • eRx = 40% • Active Medication List = 80% • Active Allergy List = 80% • Demographics (Race, Ethnicity, Preferred Language, DOB, Gender) = 50% • Vital Signs (Height, Weight, BP) = 50% • Smoking Status = 50% • Clinical Quality Measures • One Clinical Decision Support Rule • Electronic Copy of Health Information upon Request within 3 business days (Patients only) = 50% • Clinical Summaries each OV = 50% • One Test to Electronically Exchange Clinical Information • Security Risk Analysis

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