CMS Update Andy Finnegan CMS RO1 Maine Hospital Association - - PowerPoint PPT Presentation

CMS Update Andy Finnegan CMS RO1 Maine Hospital Association January 15, 2015

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PQRS 2015

CMS misidentified eligible professionals (EPs) associated with critical access hospitals (CAHs) as receiving the 2015 payment adjustment. The EPs associated with CAHs are not subject to the payment adjustment in 2015; CMS is in the process of correcting this and removing them from the 2015 Payment Adjustment File.

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PQRS Critical Access

Beginning in 2014, professionals who reassign benefits to a Critical Access Hospital (CAH) that bills professional services at a facility level, such as CAH Method II billing, can now participate (in all reporting methods except for claims-based) To do so, the CAH must include the individual provider NPI on their Institutional (FI) claims. Some professionals may be eligible to participate per their specialty, but due to billing method may not be able to participate: Professionals who do not bill Medicare at an individual National Provider Identifier (NPI) level, where the rendering provider’s individual NPI is entered on CMS-1500 type paper or electronic claims billing, associated with specific line-item services Services payable under fee schedules or methodologies other than the PFS are not included in PQRS

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CMS Announces Submission Timeframes for 2014 Physician Quality Reporting System (PQRS) Data

Reporting Method Submission Period Submission Deadline Time (All Times are Eastern) EHR Direct or Data Submission Vendor that is certified EHR technology (CEHRT) 1/1/15 - 2/28/15 8:00 p.m. Qualified clinical data registries (QCDRs) (using QRDA III format) reporting for PQRS and the clinical quality measure (CQM) component of meaningful use for the Medicare Electronic Health Record (EHR) Incentive Program 1/1/15 - 2/28/15 8:00 p.m. Group practice reporting option (GPRO) Web Interface 1/26/15 - 3/20/15 8:00 p.m. Qualified registries 1/1/15 - 3/31/15 8:00 p.m. QCDRs (using XML format) reporting for PQRS only 1/1/15 - 3/31/15 8:00 p.m. Maintenance of Certification Organizations (MOCs) 1/1/15 - 3/31/15 8:00 p.m.

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PQRS

Emphasis on 2014 Incentive AND avoiding 2016 Payment Adjustment New satisfactorily reporting requirements via claims, registry and EHR to receive incentive and avoid adjustment: 9 measures across 3 National Quality Strategy domains

• Lowered percentage of patients to be reported on for some reporting options

from 80 percent to 50 percent

• Elimination of Administrative claims or the reporting of one measure for purposes
• f avoiding the 2016 PQRS payment adjustment
• EPs may report on ONLY three measures on 50 percent of their patients to avoid

the 2016 payment adjustment (applies to only to individual claims or qualified registry reporting options

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PQRS

Incentives and Payment Adjustments in 2014 2014 is the last year for incentives EPs who satisfactorily report quality-measures data for services furnished in 2014 are eligible to earn an incentive payment of 0.5 percent of the EP's estimated total allowed charges for covered Medicare Part B Physician Fee Schedule (PFS) services provided in 2014 Additional 0.5 percent available for Maintenance of Certification 2014 is also the performance year for the 2016 PQRS payment adjustment Payment Adjustment in 2016 is -2.0 percent of EP’s Part B covered professional services under Medicare PFS

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PQRS/EMR

Incentives and Payment Adjustments in 2014 EPs who are eligible for both PQRS and the EHR meaningful use (MU) program may participate in both programs and earn incentives for both Medicare EHR incentive payments for 2014 is based on when the individual EP first demonstrated MU: 2014 Incentive for EPs participating in the Medicaid MU program is either $21,250 or $8,500 If first year of MU was: 2014 MU Incentive Is (per EP): 2011 $4,000 2012 $8,000 2013 $12,000 2014 $12,000

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PQRS/EHR Help

QualityNet Help Desk:

Portal password issues PQRS/eRx feedback report availability and access IACS registration questions IACS login issues PQRS and eRx Incentive Program questions 866-288-8912 (TTY 877-715-6222) 7:00 a.m.–7:00 p.m. CST M-F or qnetsupport@sdps.org You will be asked to provide basic information such as name, practice, address, phone, and e-mail Provider Contact Center: Questions on status of 2012 PQRS/eRx Incentive Program incentive payment (during distribution timeframe) See Contact Center Directory at http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip EHR Incentive Program Information Center: 888-734-6433 (TTY 888-734-6563)

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Chronic Care Management

The financial and human cost of chronic disease – like cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions, and mental illness – is staggering.

133 million Americans – one-third of the total population – suffer from at least one chronic disease. 70% of all deaths result from chronic diseases. 85% of all healthcare dollars go to treatment of chronic diseases. More than two-thirds of Medicare dollars are spent on patients with five or more chronic diseases.

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Chronic Care Management

In 2013, the Centers for Medicare & Medicaid Services (CMS) acknowledged the additional work involved in managing a patient following a hospital discharge was not covered by existing reimbursement. CMS created a new payment for transitional care management, or TCM. A physician who furnishes specified services for a Medicare beneficiary over a 30-day post-discharge period receives payment roughly equal to the highest payment for a new patient office visit.

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Chronic Care Management

With the publication of the 2015 Medicare Physician Fee Schedule Final Rule, Medicare will pay for chronic care management, or CCM, beginning January 1, 2015. CCM payments will reimburse providers for furnishing specified non-face-to-face services to qualified beneficiaries over a calendar month.

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Chronic Care Management

Chronic care management services

At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

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Chronic Care Management

For the first quarter of 2015, the national average reimbursement will be $40.39 per beneficiary per calendar month. This amount is subject to change thereafter based on Congressional action on the Sustainable Growth Rate (SGR) formula

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Chronic Care Management

In addition to the potential for more than $200,000 in new incremental revenue per physician (or other qualified practitioner), CCM offers providers a bridge over the chasm between fee-for-service and value-based reimbursement. By developing and implementing a CCM program, a provider will grow skill sets and internal processes critical to population health management, all the while receiving fee-for service payment to support those activities.

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Chronic Care Management

Physicians (regardless of specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists, and certified nurse midwives (or the provider to which such individual has reassigned his/her billing rights) are eligible to bill Medicare for CCM. Other non-physician practitioners and limited-license practitioners (e.g., clinical psychologists, social workers) are not eligible

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Chronic Care Management

The five capabilities: (1) Use a certified EHR for specified purposes; (2) Maintain an electronic care plan; (3) Ensure beneficiary access to care; (4) Facilitate transitions of care; (5) Coordinate care. When a provider submits a claim for CCM, the provider is attesting to the fact the provider has each of these capabilities for providing CCM.

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Market Place Enrollment

36,132 people in Maine selected 2015 Marketplace plans in the first month of open enrollment 89 percent of Maine residents who selected a 2015 plan are getting financial assistance to lower monthly premiums

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Market Place Enrollment

. Of the 36,132 Maine residents who selected a plan, 61 percent reenrolled in a Marketplace plan in 2015 and 39 percent signed up for the first time.

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Market Place Enrollment

Because the automatic reenrollment process for the 37 states using the HealthCare.gov platform (including Maine) began on December 16 and was completed for the vast majority of consumers on December 18, data through December 15 does not fully capture the number

• f people who selected plans leading up to the deadline

for Jan. 1, 2015 coverage.

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Nationwide, more than 4 million people signed up for the first time or reenrolled in coverage for 2015 during the first month of open enrollment. That includes more than 3.4 million people who selected a plan in the 37 states that are using the HealthCare.gov platform for 2015 (including Maine) From November 15 to December 26, nearly 6.5 million consumers selected a plan or were automatically reenrolled.

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Open Enrollment in the Marketplace runs from Nov. 15, 2014, through Feb. 15, 2015. Consumers should visit HealthCare.gov to review and compare health plan

• ptions. Consumers shopping for health insurance

coverage should sign up by Jan. 15, 2015, in order to have coverage effective on Feb. 1, 2015. If consumers who were automatically reenrolled decide in the coming weeks that a better plan exists for their families, they can make that change at any time before the end of open enrollment on February 15.

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Market Place Enrollment

Consumers can find local help at: Localhelp.healthcare.gov/. Or call the Federally-facilitated Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855- 889-4325. Translation services are available. The call is free.

EHR Incentive Programs Locked for Payment

• Payment process – 8 to 10 weeks to receive

payment

• Bank Information received from the MAC is:

EP NPI & EP TIN + Payee NPI & Payee TIN + Contractor ID

EHR Incentive Programs Locked for Payment

Payment is delayed when MAC data reflects:

• EP payment assignment is only related to Rail Road

payments – HITECH does not accept Rail Road banking data from the MAC

• EP has a DNF (Do Not Forward) indicator - Yes
• EP has a DNF 01 – PECOS Revalidation is

incomplete

EHR Incentive Programs Locked for Payment

Other conditions that may delay payment:

• Bank Information Requested - NA
• SSN is not setup at MAC as payment method (other

than Rail Road) – 855I form

• Reassignment - setup is incomplete
• PECOS reassignment indicator is None
• PTAN (aka Medicare ID) does not match active FFS

EHR Incentive Programs Locked for Payment

The provider’s responsibility

• The EP must work with MAC to resolve all of the

items on the previous slide

• Changes can take up to 45 days to process
• 855 I and/or 855 R
• 588 Financial form for Electronic Funds Transfer

(EFT)

NEW IRS Hospital Rules

Charitable hospitals represent more than half of the nation’s hospitals and play a key role in improving the health of the communities they serve. Some charitable hospitals have used aggressive debt collection practices, including allowing debt collectors to pursue collections in emergency rooms, have highlighted the need for clear rules to protect patients.

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NEW IRS Hospital Rules

As a condition of their tax-exempt status, charitable hospitals must: take an active role in improving the health of the communities they serve, establish billing and collections protections for patients eligible for financial assistance, and provide patients with the information needed to apply for such assistance.

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NEW IRS Hospital Rules

Limit charges. Hospitals may not charge individuals eligible for financial assistance more for emergency or other medically necessary care than the amounts generally billed to patients with insurance (including Medicare, Medicaid, or private commercial insurance).

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NEW IRS Hospital Rules

Establish and disclose financial assistance policies. Each hospital must establish and widely publicize a

financial assistance policy that clearly describes to patients the eligibility criteria for obtaining financial assistance and the method for applying for financial assistance.

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NEW IRS Hospital Rules

Establish and disclose financial assistance policies. Each hospital must establish and widely publicize a

financial assistance policy that clearly describes to patients the eligibility criteria for obtaining financial assistance and the method for applying for financial assistance.

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NEW IRS Hospital Rules

Abide by reasonable billing and collection requirements. Charitable hospitals are prohibited from engaging in

certain collection methods (for example, reporting a debt to a credit agency or garnishing wages) until they make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy.

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NEW IRS Hospital Rules

Perform a community health needs assessment. Each charitable hospital must conduct and publish a

community health needs assessment at least once every three years – and disclose on the tax form it files annually the steps it is taking to address the health needs identified in the assessment.

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If a charitable hospital fails to meet the consumer protection provisions required by the law, the hospital could have its tax-exempt status revoked. If a hospital fails to properly conduct a community health needs assessment or adopt an implementation strategy, an excise tax will apply. However, if a hospital fails to meet a requirement, but the failure is neither willful nor egregious, the hospital can correct and publicly disclose the error to have it excused, thus avoiding revocation of tax-exempt status, but the excise tax would still apply.

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In practice, many of these requirements took effect shortly after the ACA passed in 2010. Charitable hospitals have been required to make a good- faith effort to comply with the statutory requirements since the law was passed, and have been able to rely on Treasury’s proposed regulations pending finalization. Today’s regulations finalize these requirements and provide time for hospitals to phase in the new requirements.

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Questions?

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