CMS Update. Rural Health Association of Oklahoma September 20, 2011

Transcription

1 CMS Update Rural Health Association of Oklahoma September 20, 2011

2 CMS Initiatives 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

3 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

4 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

5 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

6 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

7 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

8 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

9 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

10 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: Excluded by the OIG Subject to a payment suspension Terminated by Medicaid Subject to other final adverse actions

11 New Screening and Enrollment Rule CMS-6028-F TYPE OF SCREENING REQUIRED LIMITED MODERATE HIGH 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 Criminal Background Check Fingerprinting Final Required Screening and Levels of Risk

12 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

13 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: 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

14 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

15 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

16 Improved Beneficiary Communication CMS is implementing 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

17 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)

18 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 disclosure to Other factors the Secretary considers appropriate

19 Self-Disclosure Guidance Regulations, letters and protocol can be found at

20 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

21 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

22 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

23 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

24 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

25 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.

26 Ordering/Referring PECOS File 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

27 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 , Chapter 10, Section 11.11

28 Internet-Based PECOS Enrollment Available to Part B individuals, groups, organizations and Part A providers 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

29 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

30 More Information on Medicare Enrollment Go to CMS website CMS Internet Only Manual , Chapter 10 Federal Regulations 42 CFR

31 DME Competitive Bid Round 2 Currently only affects DFW area Round 2 areas in Oklahoma, probably in 2013: Oklahoma City and Tulsa

32 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 andd0 (note the last is a zero)

33 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

34 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 for information on educational resources, code tables and descriptions, mappings, etc.

35 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)

36 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): SpecRateStats/downloads/oon-payments.pdf

37 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

38 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

39 EHR Resources EHR Helpdesk Region VI contacts: HITECH inquiry phone: HITECH Lead HITECH: Kathy Maris

40 Oklahoma Regional Extension Center To assist providers to evaluate and acquire certified electonic health record systems OFMQHIT Quail Springs Pkwy Oklahoma City, OK (405)

41 erx and PQRI PQRI is now PQRS PQRI and erx help: QualityNet Help Desk PQRI and erx Quick-Reference Support Guide for Eligible Professionals available on IACS Home

42 CMS/HHS Rural Resources CMS Open Door Forum Calls: for information on signing up for Rural Open Door listserv CMS Web site Rural Health Clinic Center HRSA Office of Rural Health Policy Rural Assistance Center one-stop shopping for all Department of HHS rural info

43 CMS Rural Resources Medicare Learning Network: Medlearn Matters Listserv: Sign up for your Medicare contractor s listserv: downloads/callcentertollnumdirectory.zip to get web address of your contractor s homepage

44 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 44

45 Administration of PCIP Varies by State Federally-administered PCIP State-administered PCIP 45

46 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. 46

47 Pre-Existing Condition Requirement Each PCIP determines how applicants must satisfy its preexisting condition requirement. In federally-run PCIP, applicants must provide: 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 47

48 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 48

49 PCIP Offers Comprehensive Benefits 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

50 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

51 2011 Plan Options and Out-of-Pocket Costs As in commercial coverage, PCIP enrollees pay monthly premiums and deductibles for coverage Beneficiary Responsibilities Standard Option Federal Plans Extended Option HSA-eligible Option State Plans Monthly premium $93 - $578 $125 - $778 $97 - $600 $69 - $1,806 Medical deductible $2,000 $1,000 $2,500 $0 - $5,000 Drug deductible $500 $250 Incl. in medical $100 - $500 or incl. Out-of-pocket limit $5,950 $5,950 $5,950 $5,950 NOTE: Above amounts represent in-network costs. More information on costs and benefits is available at NOTE: All deductible and copayment amounts are for in-network benefits. 51

52 What Enrollees Pay for Care Beneficiary Responsibilities Inpatient and Outpatient Hospital Services Standard Option Extended Option HSA-eligible Option* 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 Drug Copay $4/$40/25% $4/$30/25% $4/$30/25% State Plans Varies NOTE: Above amounts represent costs for selected in-network services. More information on costs and benefits is available at *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. 52

53 Where Consumers Can Find More Information Consumers interested in applying to PCIP may visit 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 (TTY: ) The Call Center is open from M F from 7am 10pm CST In Oklahoma call for assistance with state run PCIP program or search website for additional materials: 53

54 Regulatory Changes Rural Health Clinic Regulation Inpatient Prospective Payment Regulation Physician Fee Schedule Regulation Others?

55 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) direct or (214) office