CMS: More Hospitals Meet Meaningful-use than Expected

By Brad Ericson
Dec 16th, 2014
1 Comment

A Dec. 9 report to the Health information Technology Policy Committee indicates that almost 3,700 hospitals have attested to meeting the Centers for Medicare & Medicaid Services’ (CMS) office of e-health standards’ meaningful-use requirements, through Dec. 1.

The report indicates the number of hospitals attesting to Stage 2 doubled, in a month, to 1,681. Only 10 had attested by July 1 of 2014.

Payment for 2014 attestation ended Sept. 1, but an extension of the deadline has helped more hospitals complete compliance. Modern Healthcare reports that 2,500 hospitals were expected to be required to step up to Stage 2 this year, after meeting Stage 1 in the first years of the program.  CMS says 5,011 hospitals are eligible to participate in the program.

QRURs and Why They Matter

By John Verhovshek
Dec 16th, 2014
1 Comment

In September 2014, the Centers for Medicare & Medicaid Services (CMS) released Quality and Resource Use Reports (QRURs) for all groups and physician solo practitioners nationwide who met two criteria:

  1. At least one physician billed under the tax identification number (TIN) in 2013, and;
  2. The TIN had at least one eligible case, for at least one of the quality or cost measure, included in the QRUR.

Group practices or solo practitioners participating in the Medicare Shared Savings Program, the Pioneer ACO Model, and the Comprehensive Primary Care Initiative, however, were not included.

The QRURs contain quality and cost performance data for calendar year 2013. The information has been drawn primarily from claims data and the information reported via the physician quality reporting system (PQRS). For physicians in groups of 100 or more physicians, the data in these reports will be applied to the physicians’ payments for services paid under the Medicare Physician Fee Schedule in 2015.

The QRURs inform providers where they stand, compared to other providers of the same specialty, regarding quality measures reporting and the cost of care. CMS designated 28 quality measures and 13 sub-measures (41 total, including preventive care, cancer, diabetes, and heart conditions) to determine whether the beneficiary received the indicated treatment during 2010 for primary care and preventive services. The National Quality Forum (NQF) is working on additional measures for chronic diseases (asthma and chronic pulmonary disease) and other conditions (pneumonia, and hip and knee replacements).

The QRURs separately identify services that the physician directed (the physician billed for 35 percent or more of all of the patient’s outpatient E/M visits), services that he/she influenced (the physician billed fewer than 35 percent of the patient’s outpatient E/M visits, but accounted for 20 percent or more of the professional cost of care), and services to which he/she contributed (the physician billed for less than 35 percent of the patient’s outpatient E/M visits and accounted for less than 20 percent of the patient’s total professional cost of care). For each category, the actual Medicare costs of care were assigned per beneficiary, and were risk-adjusted by medical history and patient demographics. Percentages were provided for higher or lower cost per care, per physician, compared with peers; and whether their quality of care was better than, equal to, or worse than average for the particular quality measures.

The QRURs are fascinating to read. Consider this measure, for instance: How many patients received a systemic steroid within seven days after being diagnosed with an exacerbation of COPD? Now that there is Medicare Part D, CMS can easily determine what medications a beneficiary has taken. A doctor’s claim starts the clock ticking for the “seven days” noted in this item (date of service), and the ICD-9-CM (or, as of Oct. 1, 2015 the ICD-10-CM) code on the first claim submitted tells Medicare when the diagnosis of an acute episode of COPD was first made (first treatment day). This is one of many similar examples found in a QRUR. After seeing what’s in a QRUR, it becomes clear that accurate and complete coding is more important than ever.

In addition, the QRURs provided a way to analyze individual physician involvement with each of the patients treated. This type of data has not been previously available. It is hoped that physicians will use this data to think about the way they practice, and how they can coordinate resources with other physicians and hospitals to reduce overall costs. They can look at the reports and see where they excel in providing efficient care, and where they can make improvements in quality and/or cost by using resources better.

Much of this information is being published as CMS educates beneficiaries to compare physicians of the same specialty. Currently, beneficiaries can use the Physician Compare website to find a doctor; soon, they’ll have access to some of the quality metrics being reported in PQRS and the QRURs.

All physicians should take advantage of the opportunity to review the QRURs. These can be accessed at, using the User ID and password for the doctor or practice’s Individuals Authorized Access to the CMS Computer Services (IACS) account. If necessary, you may contact the QualityNet Help Desk for Assistance at 1-866-288-8912 or from 7:00 AM to 7:00 PM CT, Mon-Fri.

House Leaders Working To Ensure ICD-10 Implementation On October 1, 2015

By Alex McKinley
Dec 16th, 2014

The House Energy and Commerce Committee has been working with CMS ICD-10to ensure the October 1, 2015 implementation of the ICD-10-CM code set is achieved. On December 10, 2014, House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) and House Rules Committee Chairman Pete Sessions (R-Texas) issued a statement regarding their efforts to successfully meet the deadline.

“As we look ahead to the implementation date of ICD-10 on October 1, 2015, we will continue our close communication with the Centers for Medicare and Medicaid Services to ensure that the deadline can successfully be met by stakeholders,” said Upton and Sessions in a joint statement.

Upton and Sessions acknowledged the importance of the ICD-10 implementation milestone and expressed gratitude for the healthcare community’s dialogue regarding the issue. “It is our priority to ensure that we continue to move forward in health care technology and do so in a way that addresses the concerns of all those affected and ensure that the system works.”

View the complete statement here.

Award May Cement Employer’s Role in Breach Suits

By Brad Ericson
Dec 15th, 2014
1 Comment

When Audra Withers shared Abigail Hinchy’s pharmaceutical record with Hinchy’s former boyfriend, she had no idea it would lead to a legal decision affirming an employer’s HIPAA liability.

Last month, an Indiana Court of Appeals ruled that Withers’ employer, Walgreens, was as culpable as was Withers for the breach of Hinchy’s protected health information; thereby, upholding a $1.44 million civil judgment.

Hinchy sued Withers alleging negligence, malpractice, invasion of privacy, and public disclosure of public facts—but she also sued Walgreens for the cause of action as Withers’ employer.  The former boyfriend was Withers’ husband, and he threatened to use the information in a paternity lawsuit. Walgreens acknowledged the breach of private health information, but argued  it was exempt from liability for acts of an employee who knowingly violated company policy. Before a jury, Walgreens lost and appealed the decision.

The court of appeals cited a number of Indiana cases to explain the concept of responde et superior, deciding that an employee is acting within of the scope of work, when the employee and the work being done is within the employer’s control. It also found that under Indiana law, Withers had a duty of confidentiality to Hincy, and that she had breached that duty by reviewing and disclosing the records without permission. Walgreens, it said, was liable because its attachment to Wither’s negligence and professional malpractice.

Although employers’ liability in cases like this isn’t new, legal experts say the decision by a state court in a civil case, using HIPAA as a  standard of care, could be groundbreaking.



Enrollment Verification Soon Required for Part D Prescribers

By Renee Dustman
Dec 15th, 2014
1 Comment

At first glance, a recent announcement by the Centers for Medicare & Medicaid Services (CMS) seems to suggest that prescribers of Medicare Part D drugs have been given a six-month reprieve from certain program requirements that were supposed to go into effect June 1, 2015. If you read the article in its entirety, however, you learn otherwise.

The “Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” (42 CFR 423.120(c)(6)) final rule, published in the Federal Register on May 23, 2014 requires physicians and other eligible professionals who write Medicare Part D prescriptions for Medicare patients to enroll in an approved status, or to have a valid opt-put affidavit on file for their prescriptions to be covered under Part D.

CMS announced on December 5, 2014 that it is delaying enforcement of this requirement until December 1, 2015. This delay, however, is for Medicare contractors, not prescribers.

“Nevertheless,” CMS states in MLN Matters® special edition article SE1434, “prescribers of Part D drugs must submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by June 1, 2015, or earlier … .”

CMS is only postponing enforcement of the requirement for six months to ensure that MACs have sufficient time to process provider enrollment applications and opt-out affidavits, and consequently to avoid a lot of prescription drug claims denials by beneficiaries’ Part D plans.

Prescribers may submit their enrollment application electronically using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper CMS-855I (Medicare enrollment) or CMS-8550 (Part D-only enrollment) application. Opt-out affidavits are submitted to the MAC within the prescriber’s jurisdiction. Note that opt-out affidavits must be submitted every two years, and a National Provider Identifier (NPI) is required.

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