Disclaimer HEALTHCARE REFORM 8/18/2015. CS EYE - Compliance Specialists, Inc. Compliance, Medicare Advantage and Accountable Care Organizations

Transcription

1 HEALTHCARE REFORM Compliance, Medicare Advantage and Accountable Care Organizations Jon Weeding President CS EYE CS EYE - Compliance Specialists, Inc. Outsource compliance and medical billing Assisted over 1000 Optometry practices enhance their compliance and profitability since Clients in 46 states and over 400 billing clients (we have to deal with compliance issues you do) CS EYE is recognized by CMS as an Independent Review Organization Research based on CMS, HHS, OIG and findings from clients and audits we have been asked to help with Disclaimer This material is designed to offer basic information for creating a compliant atmosphere in the small private practice. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This presentation is intended as an educational guide and should not be considered a legal/consulting opinion. 1

2 ACA and Insurance Provider Driven Compliance Compliance Policies Risk Assessments Audits Medicare Advantage Plans (MA) Accountable Care Organizations (ACO) Healthcare reform driven compliance Funding for enforcement Patient Protection and Affordable Care Act put teeth into the laws already in place Audits are big business $23 for $1 Phase 2 HIPAA audits have begun Compliance with Insurance Providers Criteria for on-going participation with plans (narrow networks) Compliance Programs in Place Standard of Care Reporting Chronic Conditions Attestation/EHR Collaborative Care 2

3 Written Policies and Procedures Policy - Compliance Officer; Privacy Officer; Public Information Officer and Security Officer Policy - Business Associates Defined; BAA Template Policy - Practice Standards Policy - Procedures and Adherence to Health Care Laws and Regulations Policy - Record Retention, Privacy and Security Policy - Auditing, Benchmarking and Monitoring of Charts and Claims Policy - Training and Education Policy - Communication and Compliance Reporting Policy - Enforcement, Employment and Employee Discipline Policy - Inspection Risk Assessment Identify all potential risks Create a document of findings of all risks Identify HIPAA regulation each risk potentially violates Identify each risk as High, Moderate or Low Identify mitigation plan for each risk and assign responsibility Create a time table for mitigation of risks identified Standard of Care Fee for service models being replaced by value based models (shared risk) Providers are analyzing data based on cost of care Audits based on ranking of costs Care outcome based to drive cost down Value vs Volume Collaborative care with other providers 3

4 Reporting Chronic Conditions Value based models (shared risk) Dollars based on entire care process vs fee for service Additional dollars based on increased percentage of chronic conditions present in a period Audits to verify proper reporting Risk Adjustment Audits Collaborative care with other providers Attestation/EHR Attestation with Certified EHR for Meaningful Use Stimulus funds to drive reform with ultimate goal of reducing healthcare costs through coordinated care Tracking who is opting in and fully participating in healthcare Risks of not attesting: Not part of panels in the future Lost patients Age of Big Data Collaborative Care Claims data to review panel members Attestation for meaningful use Reporting Chronic Conditions $$$$ PQRS/E-Prescribe Standard of Care Reporting Outcomes (registries) Secure communication with patients and providers Collaborative Care 4

5 HEALTHCARE REFORM MCOs, MAs and ACOs MCO = Managed Care Organizations MA = Medicare Advantage Plans ACO = Accountable Care Organizations Review impact from each of these MCOs, MAs, and ACOs Changing the way healthcare is delivered and paid for (fee-for for-service vs shared risk value based payments) Driven by primary care provider and outcome based Incentives for saving $$ Managed Care Organizations Common network-based managed care programs: Health Maintenance Organization (HMO) Independent Practice Association (IPA) Preferred Provider Organization (PPO) Point of Service (POS) Private Fee-For-Service (PFFS) 5

6 Managed Care Organizations Impact: Overall impact is widely debated Proponents: Increased efficiency Improved overall standards Led to a better understanding of relationship between costs and quality State there is not consistent, direct correlation between the cost of care and its quality 2002 study estimated that the "cost of poor quality" caused by overuse, misuse, and waste amounts to 30 percent of all direct health care spending. The emerging practice of evidence based medicine is being used to determine when lower-cost medicine may in fact be more effective. Managed Care Organizations Impact: Overall impact is widely debated Opponents: For profit managed care has been an unsuccessful health policy Higher costs (25-33% higher overhead at large HMOs) Increased number of uninsured Health care providers driven away Downward pressure on quality National Committee for Quality Assurance showed worse scores on 14 of 14 quality indicators Managed Care Organizations Impact to Optometry Capitation plans Place ODs in role of micro-health insurers Assuming responsibility for managing the unknown future health costs for their patients Transfers risk of providing services at capitated rates Replacing traditional Medicaid with Vision Care Plans providing routine vision care Reduction in reimbursement 6

7 Medicare Advantage Plan A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefit An alternative to Traditional Medicare plans Many seniors are transitioning to Medicare Advantage Similar coverage to Traditional Medicare Higher premiums with better coverage May include prescription drug coverage May include routine eye care coverage May include dental coverage Medicare Advantage Plan 55 Million are Medicare Eligible 10,000* a day are becoming eligible People are living longer and requiring more care 31% of Medicare Recipients have moved to MA plans 7

8 Medicare Advantage Plan UnitedHealth and Humana make up one third of all MA plans. "Medicare overpayments to private plans, : Shifting seniors to private plans has already cost Medicare $282.6 billion." Ida Hellander, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D. International Journal of Health Services, May 10, 2013 (online first), Vol. 43, No. 2. DOI: /HS.43.2.g Medicare Advantage Plan Medicare pays these privately run plans a set "premium" per enrollee for hospital and physician services (averaging $10,123 in 2012) based on a prediction of how costly the enrollee's care will be. Risk adjustment was implemented to pay Medicare Advantage Plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (age and gender) as well as health status. 8

9 Medical Record Documentation Important for Risk Adjustment Accurate risk adjusted payment relies on complete medical record documentation and diagnosis coding. CMS conducts risk adjustment data validation by medical record review. Specificity of the ICD-CM diagnosis coding is substantiated by the medical record. Risk Adjustment Audits Seeing a significant increase in audit activity CMS audits about 30 Medicare Advantage Plans (MA) contracts each year. Passed down to providers (physicians) MA payments based on number of members Increased payments if claims show increased percentage of sick people during a reporting period. Risk Adjustment Audits Risk Adjustment audits of physicians pulling charts to review chronic care patients. New claim forms can hold up to 12 diagnosis. Recommend reporting chronic conditions on all claim forms. May require provider to resubmit. Not usually a recoupment type audit. Stars Ratings affected and can reduce payments Reduction in Stars Ratings can end MA plan due to reduced funding 9

10 Example PA Medicare Advantage plan stated ODs were main culprit behind drop from 5 stars to 4 stars (standard of care, chronic disease, and communication). If plan falls to 4 stars and doesn t come back up to 5, the plans funding is cut drastically, typically leading to failure/closure of that MA plan. Standard of care and communication Websites showing fees, reviews and claims data based on standard of care UnitedHealth reduced panel of optometrists in PA by 10%. No data showing how decision made, but Stars Ratings for Medicare Advantage Plans 1-5 stars covering health services Measuring the overall score for quality of those services and covers 36 different topics in 5 categories Staying Healthy: screenings, tests, and vaccines; Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy Managing chronic (long-term) conditions: includes how often members with different conditions got certain tests and treatments that help them manage their condition Ratings of health plan responsiveness and care: includes ratings of member satisfaction with the plan Health plan member complaints and appeals: includes how often members filed a complaint against the plan Health plan telephone customer service: includes how well the plan handles calls from members Accountable Care Organizations An accountable care organization (ACO) is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. The ACO is designed to address a key problem: The fragmented, disconnected nature of fee-for-service health care delivery in most parts of the U.S. and the ways in which it rewards volume instead of results. 10

11 Accountable Care Organizations Stated Benefits to PROVIDERS Gain immediate access to clinical information Improve workflow and care coordination Enhance communication with all members of the patient s care team Prevent, diagnose, and treat certain diseases or combinations of conditions, in particularly complex cases Improve the application of evidence-based medicine through disease management protocols and clinical decision support Increase physician and staff job satisfaction by creating a hassle-free clinical practice Accountable Care Organizations Stated Benefits to PATIENTS Deliver coordinated care across physicians offices and hospitals Achieve better health outcomes Enable all care team members to access full medical history Stop repeatedly filling out forms on medical history and repeating unnecessary tests Increase patient engagement and satisfaction 11

12 Accountable Care Organizations 600+ to date with 287 CMS funded and approximately 250 private-sector 3 Models (Pioneer, Shared Savings, Advance Payment Model) Pioneer ACO Model support organizations with experience operating ACOs or similar arrangements to provide more coordinated care to beneficiaries at a lower cost to Medicare. 32 ACOs participated in this demonstration project. Shared Savings Program rewards ACOs that reduce their growth in health care costs while putting patients first and meeting performance standards on their quality of care. The organization shares in the costs savings with CMS (85%). 220 ACOs participated in this program. Advance Payment ACO Model is designed for physician based and rural providers who are already interested in the Shared Savings Program and are coordinating high-quality care to Medicare patients. This model allows selected participants to receive upfront and monthly payments, which they can use to make important investments in their care coordination infrastructure, such as purchasing electronic health records and hiring nurse diabetes educators. 35 ACOs participated in this demonstration project. Health care leaders are focusing on finding ways to achieve Triple Aim outcomes the simultaneous improvement of the health of a defined population, the experience of each individual within it, and the affordability of care. Enter the ACO. The Affordable Care Act, for example, set aside $10 billion for the creation of a Medicare Center for Innovation to evaluate new approaches to health care, such as ACO reforms and payment models, through

13 10 Largest ACOs in US Today 1. Advocate Partners, IL 553,000 Enrollees 2. Partners Healthcare, MA 550, Allina Health, MN 331, UnityPoint Health, IA 266, Banner Health Network, AZ 240, OSF HealthCare System, IL 110, UW Health ACO, WI 109, Heritage California ACO, CA 92, Physician Org of MI ACO, MI 83, AHS ACO, MJ 81,000 ACO HEALTH PLAN EXAMPLE 13

14 Key Issues and Challenges for ACOs Engaging physicians to change practice patterns and practice more in teams: Following professional medical guidelines Implement EHRs Treating patients with chronic illness as an interdisciplinary team and implement team-based care Standardized reporting metrics across multiple payers Hiring Health Information Technology support staff to maintain functionality of EHRs 14

15 Impact on Optometry Goal for a reduction in health care expenditures from fee-for-service from 78% to 50% - Value based Participation risks or reward: May increase pay with shared savings May lead to exclusion and loss of patients Group practice drove 500 patients per month to their facilities by proactively promoting the benefits of their group joining ACO (raised HEDIS scores) HEDIS DEFINED HEDIS (healthcare Effectiveness Data and Information Set) performance measures in managed care. Developed and maintained by the National Committee for Quality Assurance NCQA. Required for Medicare Advantage plans 75 HEDIS measures are divided into eight domains of care o Effectiveness of Care o Access/Availability of Care o Experience of Care o Health Plan Stability o Utilization and Relative Resource Use o Informed healthcare choices (availability of new member orientation, education and language translation services, etc.) o Health Plan Descriptive Information Accountable Care Organizations Risks To Optometry Patient base attrition due to exclusionary contracts Decreased efficiency due to increased documentation and reporting Benefits to Optometry Increased patient based due to increased contracts Increased payments with VALUE BASED model (new healthcare dollars introduced into the system) Increased care based on outcome analysis Hope it works medicine Specific, outcome based, patient specific care 38 year old, diabetic with retinopathy care plan 65 year old, diabetic with retinopathy care plan 15

16 Accountable Care Organizations Requirements for participation Be present at the table Compliance minimums EHRs and communications with other specialties Standard of care must be followed Outcome based Registry Sources: oig.hhs.gov web sites. Information gathered from various sources within these sites Henry Powderly, Bundled Payment Partners Drop Off Medicare Advantage 2015 Data Spotlight: Overview of Plan Changes, Dec 10, 2014 Gretchen Jacobson, Anthony Damico, Tricia Neuman, and Marsha Gold How to Think like an ACO, NextGen Healthcare, ebook Vision Monday, A.C.O. Where Do I Fit In, What you need to Know about Accountable Care Organizations Audit materials and insights gathered from working with Optometry clients throughout the US as they work with Insurance providers and government agencies. Ida Hellander, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D. International Journal of Health Services, May 10, 2013 (online first), Vol. 43, No. 2. DOI: /HS.43.2.g David Muhlestein, Health Affairs Blog 16

17 HEALTHCARE REFORM Compliance, Medicare Advantage and Accountable Care Organizations Jon Weeding President CS EYE 17