THE 2007 DRA UPDATE. By RSVP Consulting An Outsourcing Solution

Transcription

1 THE 2007 DRA UPDATE By An Outsourcing Solution

2 President & Founder

3 Current Hot Topics The 8 Musts Know your cost and your billings & collections Charts DRA Contrast Q codes Customers not patients Billing concepts / Using the web Local Tenens 2007 Challenges/ CMS Updates 3

4 Map Charges to Receipts CHARGES TOTAL RECEIPTS 6% 0% 5% 8% 2% 0% 23% 1% 5% 0% 7% 10% 5% 0% 16% 3% 0% 15% 1% 0% 11% 1% 1% 1% 0% 0% 39% AETNA ANTHEM BC/BS BC/BS CIGNA COMP (W/C) GHI HIP MEDICAID MEDICARE OXFORD HEALTHNET SELF PAY UNITED HEATHCARE COMMERICAL 40% AETNA ANTHEM BC/BS BC/BS CIGNA COMP (W/C) GHI HIP MEDICAID MEDICARE OXFORD HEALTHNET SELF PAY UNITED HEATHCARE COMMERICAL 4

5 Know Your Payer Mix Payment policy is State and payer specific Payer Mix may vary depending on location 5

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7 Deficit Reduction Act Why 22% growth in Imaging Congress seeks to level the payment playing field between HOPD and freestanding without considering shared resources and that procedure payments are calculated very differently in each setting. Hospitals have historically had to absorb self pay and bad dept but have shared resources and fundraising ability.. Some states give hospitals grants to help compensate for bad dept. Freestanding centers are not obligated to scan every patient they have freedom of choice but do not have fund raising and state grants. 7

8 Update on the DRA In March 2007 Congress drafted legislation Access to Medical Imaging Act of 2007 (H.R ) sponsored by Carolyn McCarthy was drafted and we have 143 signatures as of as of July 20, 2007 Calls for a two-year moratorium and an investigation on the impact these cuts will have Senators Gordon Smith & John Rockefeller Introduced access to Imaging Act (S.( A bill to amend title XVIII ) to the senate March 8, signatures as of July 20, 2007 On July 23 NCQDIS Washington Fly-in to disscuss no further cuts to Imaging Congressman Bill Pascrell-Patterson, Patterson, NJ & Mike Ferguson NJ, Tom Reynolds NY (Xavier Becerra intro ducing a bill with quality measures). 8

9 110 Session in Congress March 2007 Bills were reinstated in both Senate reinstated May 8, 2007 Congress reinstated on March For 2 year moratorium in the DRA DRA needs Momentum in 2007 join a lobby effort Lack of involvement will roll everything forward as planned by Government NCQDIS is an organized effort to appeal language in the DRA 9

10 On The Hill 10

11 DRA Mandate Screening 2007 UL Abdominal aortic aneurysm Colorectal cancer screening Screening digital rectal examination, code G0102; and Screening prostate specific antigen (PSA) blood test, code G0103. No patient deductible 11

12 Not affected by DRA Breast MRI 12

13 Hospital Outpatient Landscape 2006 Shift to ASP based payment for contrast agents Change to new Q-codes for LOCM based on concentration No reduction in procedure payment Gain sharing for community hospitals 2007 Technology add-ons 1.5% 14% increase Medicare dependant Hospitals Emergency medical treatment specialty hospitals Payer increase of 3.4% Payment reductions for PET and PET/CT(DRA) Hospital compare 13

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15 DRA Free-Standing Facilities Landscape % reduction on technical component payment; reduction based on families Professional fee no change 25% reduction on technical component payment; reduction based on families 2007 Capping of payment to the lesser of the physician fee schedule or hospital payment 2007 Policy & Cap list 0.3 increase in practice expense Pro fee is increased 0.3 through PE 15

16 New York Manhattan 01 Physician - Par Physician - Par Par non F Fee schedule Fee schedule Capped Par 2007 CPT MRI TC component Reduced by 25% TC- HOPPS Pro Fee Total Pelvis w/o $ $ $ $ Abdomen w/o $ $ $ $ $ $ 1, Abdomen w&wo $ 1, $ $ $ Pelvis w&wo $ 1, $ $ $ $ $ 1, NY 01 fee schedule 2007 NY CAP

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18 Kansas Local (007004) Physician - Par Physician - Par Fee schedule Fee schedule Capped Par 2007 CPT MRI TC component Reduced by 25% TC- HOPPS Pro Fee Total Pelvis w/o $ $ $ $ Abdomen w/o $ $ $ $ $ $ Abdomen w&wo $ $ $ $ Pelvis w&wo $ $ $ $ $ $ 1, Kansas Fee schedule 2007 Kansas Cap

19 Contrast 2007 Price Changes Quarterly Code Description Amount Q9945 LOCM <=149 mg I/ml 1 ML $0.294 Q9946 LOCM mg 199mg I/ml 1 ML $1.780 Q9947 LOCM mg 249mg I/ml 1 ML $1.275 Q9948 LOCM mg I/ml 1 ML $0.351 Q9949 LOCM mg 349mg I/ml 1 ML $0.380 Q9950 LOCM mg 399mg I/ml 1 ML $0.229 Q9951 LOCM 400+ mg I/ml 1 ML n/a Q9952 Inj Gad-base MR contrast 1 ML $2.757 Q9953 Inj Fe-based MR contrast 1 ML $ Pricing contrast quarterly

20 Customers Not Patients Consumer directed Health Plans Radiology today Price transparency 20

21 Using the Web Pre Cert expire 30 or 90 days Insurance eligibility Web Insurance Pre-cert Dashboard Registration forms Medical clearance forms Prescription pads 21

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23 Locum Tenens Billing Regular Physician not available Medicare patient requested service from regular physician Substitute physician can not provide service to a Medicare patient for a continuous period of 60 days Q5 modifier must be billed with any charges done by substitute physician Q6 (member of your group practice covers) This arrangement can be with more than one physician 23

24 CPT updates 2007 Mammo/Ultrasound Unilateral Mammo Bilateral Mammo Screening bilateral Mammary Ductogram,, Single Mammary Ductogram,, Multiple CAD CAD Screening Ultrasound Breast CODES BASED ON

25 Know your CMS changes 2007 CMS Publishes pricing for patients NPI drop dead date May NPI application Rejections start July 1, 2007 if no NPI is on form 1500 (8-05) NPI ready Hospital Form updated on March of 2007 UB-04 Medicare Deductible changes 2007 H=$ O=$ CPT changes 25

26 Challenges Increasing competition as a result of DRA Pre-cert through radiology vendors Credentialing panel closed or not allowing new members due to saturated marketplace Lock out of network (Care Core) Credentialing for radiology vendors CAQH National credentialing application Online Fill in Application for Credentialing Know your payer requirement s (medical necessity) 26

27 Challenges Choosing an outsourcing vendor and/or internal system Audit Medicare Cert Program monitors error rates ACR accreditation online application United Healthcare now requires ACR 27

28 Keys to Your Success Keep updated with DRA changes and Insurance Payer Mix is critical to monitor % moving to Medicare DRA Streamline practice by incorporating the WEB Review expense against revenue Audit your practice charges vs. payments Watch your AR days Make sure your billing software 2007 ready Have a pre-cert upfront process 28

29 Key Musts Know how DRA is affecting you Get involved with Access to Imaging Contrast Use Q codes Customer landscape changes Web real time 2007 CMS updates 29

30 Thank You THE END 30