Know What a Medicare ACO is Before You Jump

With the Centers for Medicare & Medicaid Services (CMS) predicting the number of affordable care organizations (ACOs) will double to 300 by the end of 2012, it is time to start thinking about what you and your providers need to do to become Medicare ACO partners.

How does a Medicare ACO function and how will it potentially affect your office?

Born of the Affordable Care Act, Medicare ACOs are made up of a group of Medicare providers and suppliers. Under the ACO, the providers and suppliers agree to band together, coordinating care, documentation, and billing for patients, improving quality and cost savings in the process. Providers, payers, and newly established groups have applied to CMS for approval to start an ACO, which if approved must operate for at least three years.

An ACO’s quality performance is evaluated in five areas: care coordination, patient safety, preventive health, patient/caregiver experience, and at-risk population/frail elderly health.

CMS’ Medicare Shared Savings Program (MSSP) bases financial incentives to ACOs on successful cost reduction via care coordination. Under the MSSP, ACOs serve a minimum of 5,000 beneficiaries and must provide enough primary care physicians to easily serve the population. Before applying for MSSP status, an ACO must establish legal and governance structures, cooperative clinical and administrative systems and a shared savings distribution protocol.

Incentive payments are based on comparing an ACO’s annual incurred costs relative to CMS determined benchmarks and ACOs can choose to be reimbursed based on a “one sided” or “two sided” model. The one sided model allows the ACO to share a maximum of 50 percent for the first two years and savings or losses the third year. The two sided model allows a maximum of 60 percent sharing of savings and losses for all three years. Shared loss grows from 5 percent to 10 percent over the three year period.

A key to success is the communication of patient information, which adds a new perspective on current, interoperative electronic health record (EHR) systems. ACOs were ideated to encourage seamless treatment of patients by teams of providers from different entities and disciplines. Universally reliable documentation and classification of each patient may help providers meet incentives while providing improved quality of care.

If you are updating your EHR, investigate its ability to capture and communicate the information needed by other practices, physicians, and providers who may be joining your practice in a future ACO.

November 26th, 2012

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EHR, Emails Can Make or Break Your Practice’s Success

When implementing or updating your practice’s electronic health record (EHR) system, an independent think tank cautions that sometimes the prescribed cure to a practice’s communications problems may make them sicker.

The Centers for Studying Health System Change surveyed providers, EHR vendors, and other experts to determine how EHRs and other advancements affect communication with patients and providers. Results may help you more carefully implement EHRs and other new tools in your practice.

While EHRs, instant messaging (IM), and email allow information to be quickly transferred, they can prove distracting in the exam room. “It’s like having a two year-old in the room,” one survey respondent said. Instant messages from other providers, focusing solely on a computer screen’s prompts, and other distractions may interrupt direct communication with the patient. In addition, busy providers report falling into a trap of asking the EHR’s prompted check box questions and fewer open-ended questions, allowing them to miss elements not on the EHR template.

However, providers say they can pull up the patient’s previous visit, test, and radiological information before entering the exam room, freeing them to spend more time evaluating the patient. The study says EHRs in the exam room had either a neutral or positive impact on perceptions of provider-patient communication in terms of overall quality of communication about medical and psychosocial issues. However, other studies find that already inadequate provider-patient communication skills did not improve after EHRs were implemented.

Providers who utilize email with their patients believe email broke barriers and improved the quality of the provider-patient relationship by enhancing communications in-between visits and reducing telephone tag. Providers also found email with other providers boosts communication with peers, making it easier to share information about particular patients.

But participants caution that providers and practice managers should define and train staff on what information should be communicated one-on-one and what should be communicated via email or the EHR. For complicated situations, participants say nothing should replace the interactive aspect of face-to-face or phone conversations.

To implement EHR systems for the first time or when upgrading, remember these communication tips from the survey:

• Evaluate existing communication providers have with their patients and with others, and then develop a plan to improve it before upgrading EHRs.
• Engineer the EHR and its use so patients remain the primary focus of the visit.
• See if the EHR vendor will develop the template to prompt for more open-ended questions.
• Identify and train providers and staff on how to best use EHRs, email, and instant message and when a situation absolutely requires one-on-one communications.

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Get Primed on Stark Law

By Mary Pat Whaley, CPC, FACMPE

In health care, we are “blessed” with an abundance of rules, policies, standards, and laws. Three important regulations are the False Claims Act, Stark Law, and Anti-Kickback Statute, which you should not only know about, but should be actively managing via a robust compliance plan.

To help keep your practice out of harm’s way in regards to the Stark Law, here are some things you should know:

Stark Law (Physician Self-Referral)

When: Section 1877 of the Social Security Act, also known as the physician referral law, is commonly referred to as the Stark Law. When enacted in 1989, it applied only to physician referrals for clinical laboratory services. In 1993 and 1994, Congress expanded the prohibition to the additional designated health services listed below.

What: Stark Law “prohibits physicians from making referrals for designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies,” according to the Centers for Medicare & Medicaid Services (CMS). Specifically, covered DHS include:

• Clinical laboratory services
• Physical therapy services
• Occupational therapy services
• Outpatient speech-language pathology services
• Radiology and certain other imaging services
• Radiation therapy services and supplies
• Durable medical equipment (DME) and supplies
• Parenteral and enteral nutrients, equipment, and supplies
• Prosthetics, orthotics, and prosthetic devices and supplies
• Home health services
• Outpatient prescription drugs
• Inpatient and outpatient hospital services

Penalties: Penalties for violating the Stark Law include denial of payment, refund of payment, imposition of a $15,000 per service civil monetary penalty, and imposition of a $100,000 civil monetary penalty for each arrangement considered to be a circumvention scheme.

Be Compliant: To help you stay in complaince with the Stark Law:

1. Offer all patients a written list of choices for obtaining the care your physicians are recommending.

2. Disclose any financial relationship with any entity that is on the list offered to patients.

November 15th, 2012

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Follow 2013 Instructions for Splints, Casts, and Intraocular Lenses Payment

Medicare payment continues in 2013 for splints, casts, and intraocular lenses implanted in a physician’s office. Effective Jan. 1, 2013, the Centers for Medicare & Medicaid Services (CMS) instructs:

• For splints and casts, HCPCS Level II Q codes should be used when supplies are indicated for cast and splint purposes. This payment is in addition to the physician fee schedule procedure payment for applying the splint or cast.
• For intraocular lenses, payment is only made on a reasonable charge basis for lenses implanted in a physician’s office (HCPCS Level II codes V2630 Anterior chamber intraocular lens, V2631 Iris supported intraocular lens, and V2632 Posterior chamber intraocular lens).

The 2013 payment limits for splints and casts are based on the 2012 limits announced in last year’s Change Request (CR) 7628, increased by 1.7 percent. 2013 payment limits for splints and casts are:

Splints and casts furnished in 2013 will be paid based on the lower of the actual charge or the aforementioned payment limits.

See MLN Matters MM8051 and CR 8051 for more information.

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Radiology Today: How to Benefit from Medicare Denials

Medicare’s radiology denials hold a wealth of information that can benefit your practice or facility. They can help you appropriately issue advance beneficiary notices (ABNs), properly bill claims, and educate physicians on medical necessity. Terry Kelly, CPC, recently authored an article for Radiology Today that summarized key benefits that can be gleaned from Medicare denials and specifically how to use them to improve your health care workplace.

“Though it will take time to review denials and track and trend issues, doing so will help patterns emerge,” she wrote, “allowing you to implement policies and procedures to address the denials and keep appropriate reimbursement within your practice.”

Read the full article.

November 4th, 2012

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