Medicare

OIG Work Plan Updates: September 2018

The September 2018 additions to the HHS OIG Work Plan were limited to two, both somewhat esoteric and unlikely to impact the majority of healthcare providers.

  1. Review of Opioid Use in Indian Health Service: Consistent with prior OIG work plan items regarding Medicare Part D and Medicaid, this work plan addition will seek to “determine the extent to which beneficiaries are receiving extreme amounts of opioids through Indian Health Service (IHS), as well as IHS-employed prescribers and IHS-run pharmacies that have questionable prescribing or dispensing patterns. This review will also determine how IHS prevents and detects opioid misuse or abuse, as well as how it enforces its opioid-related policies.”

  2. Follow-up Review of Head Start Grantee: Pertains to one specific entity, not applicable to wider constituencies at this time.

New additions to the work plan of import added in August 2018 during the height of vacation season that slipped by VantagePoint scrutiny included:

  1. Physician Billing for Critical Care Evaluation & Management Services: As an exclusively time-based service, physicians must clearly document the time spent evaluating, providing direct care and managing the patient in order to qualify for reimbursement of a critical care E/M visit, per the OIG “This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.”

  2. Hospitals' Compliance with Medicare's Transfer Policy With the Resumption of Home Health Services and the Use of Condition Codes: Hospitals transferring a patient to another facility or home health service are subject to a reduction in DRG payment. The OIG seeks to “determine whether Medicare appropriately paid hospitals' inpatient claims subject to the postacute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.”

The Gift that Keeps on Giving: The 21st Century Cures Act & Updates to the LCD Process

The Centers for Medicare & Medicaid Services (CMS) has posted revisions to chapter 13 of the Medicare Program Integrity Manual (PIM). This revisions were required by a provision of the 21st Century Cures Act meant to enhance the transparency of the local coverage determinations (LCD) process administered by Medicare Administrative Contractors (MACs).

Key changes include a clearer process roadmap in language that can be understood by the different constituencies eligible to request an LCD, including beneficiaries; streamlined process for requesting new LCDs; and expansion of Contractor Advisory Committee (CAC) meeting format options and individuals eligible to participate.

VantagePoint's Take: Physician Fee Schedule Proposed Rule Listening Session

VantagePoint HealthCare Advisors consultants have been monitoring the various CMS announcements, propaganda, and industry reactions to CMS proposed changes to Evaluation & Management (E/M) documentation standards, coding and reimbursement since first announced  in late Spring by CMS Administrator Seema Verma.

 On Wednesday, August 22, 2018, The CMS Administrator opened up the Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session with much of the same ballyhoo that has accompanied the rollout of the Patients Over Paperwork initiative and then CMS staffers got down to explaining the details to the industry audience on the call. CMS promotes the E/M and related fee schedule changes as "focused on reducing administrative burden while improving care coordination, health outcomes and patients’ ability to make decisions about their own care." and address concerns of physicians who "struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care." (Medicare Learning Network Listening Session Handout, 8/22/2018).

Two concerns standout, among many, regarding the CMS proposal. Firstly, in one breath, the CMS presenters stated that clear and concise medical record documentation is critical to providing quality care and is required for reimbursement, and on the other hand, are suggesting a minimum documentation standard that arguably will not promote the use of the patient medical record for substantiating quality, let alone tell the patient story. While VantagePoint consultants concur that the 1995 and 1997 documentation guidelines for E/M visits bear some updating, we also know from our experience auditing client records that more robust and detailed documentation is needed to tell the patient story, not less.

The other concern, shared by VantagePoint, is one that seemed to dominate the comments and questions from those selected to speak during the listening session - the fee schedule and new add-on codes. In the proposed fee schedule world, providers who currently provide the majority of their services at E/M level 1 - 3 might win, and those with high numbers of complex patients on their panels or E/M level visits of 4-5 will lose or need to justify the gamut of add-on codes to get up to the same par level. Our quick math using the charts provided in the handouts, including the various (and confusing) add-on payments, including the murky multiple procedure payment adjustment, did little to change the opinion of some of our consultants that the initiative is more about wrapping up a fee reduction in a patient-friendly wrapper than reducing provider stress.

The transcript of the listening session should be available online in a week to ten days and there is still time for stakeholders to submit formal comments, but not much time. The deadline is September 10, 2018 [Comment Here: https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions ]

Trojan Horse? The Patients Over Paperwork Initiative

The allusion of the Trojan Horse is often used (and maybe overused) to describe situations in business or politics in which the true motivation of an initiative or proposal is wrapped in something positive or innocuous. The "Patients Over Paperwork" initiative promoted by the Centers for Medicare and Medicaid (CMS) has all the hallmarks of that mythical wooden vessel the Greeks used to gain entry into the city of Troy.

Direct-care providers [physicians, nurse practitioners, physician assistants] are understandably vulnerable to buying into the arguments that reducing documentation requirements and updating guidelines for evaluation and management services (E&M) is a benefit to patient care because ostensibly, providers will have more time to spend with patients. Fair enough. The promise of efficiency that was supposed to be inherent once a practice implements an EHR has not been fully realized and many providers are spending more time than ever on their documentation obligations. Furthermore, accurately coding E&M services can be tricky and even trickier to defend upon audit. Pretty tempting to accept this initiative on it's face and 'open the gates' to the idea that lessening the requirements for documentation will liberate time for patients.

Revising documentation requirements and E&M guidelines is a great idea, but shouldn't be construed as merely a patient-centric effort. CMS is also proposing to eliminate the higher level fees associated with the highest level of E&M visit care. Does this incentivize providers to spend more time with the patient and less on paperwork? Or does this incentivize providers to increase the volume of patients they see, rather than the quality of time spent with current patients while reducing the quality of documentation? The CMS site devoted to this initiative states the program is meant to, among other things, improve the beneficiary experience.

What is the real goal of this proposal? Eliminating the higher level of reimbursement for level 4 and 5 visits, reimbursement levels designed to compensate providers for the time and work effort associated with the most complex patients certainly feels more like an effort to reduce Medicare expenditures than a patient-centric initiative.

99% of Physicians Seeking APM Bonuses in 2017 Qualified

Healthcare Financial Management Association (HFMA) reported that 99% of physicians who sought advanced alternative payment model (APM) bonuses in the first year (2017) did qualify.  This is not surprising due to the relatively low thresholds and the fact that those who do apply do so knowing it is attainable for their group.  Forthcoming changes to MACRA include the launch of an all-payer combination option, which allows clinicians to be eligible for the 5 percent APM bonus if they see patients in both Medicare and qualifying payment models offered by Medicaid managed care plans and Medicare Advantage plans.  Moving forward, clinicians should continuously review their eligibility and their strategy to qualify or join models of care that offer such incentives.

Conditions of Participation

Ordinarily, the loss of Medicare or Medicaid billing privileges is connected to allegations of Fraud or Abuse. Make no mistake, the fear of being placed on pre-payment review alone or having reimbursement suspended during an investigation is enough for many hospitals to justify their compliance efforts.

The case of Overland Park, Kansas-based Blue Valley Hospital is a bit different. Under Medicare rules for acute care hospitals, a facility must have an average of 2 inpatient admissions per day with an average 2-day length of stay in order to maintain status as an inpatient hospital for purposes of reimbursement. Blue Valley Hospital asserts that the requirements are arbitrary. The hospital performed outpatient surgeries at a ratio of 2:1 over inpatient surgeries in the period examined per Ellison (2018, June 12) and of the inpatient surgeries performed, patient were often discharged prior to the 2 day standard.

Supreme Court may revisit a False Claims Act decision

The Supreme Court may revisit a a key False Claims Act decision and the results may impact pending and new cases. According to an article published today in McKnight's Long Term Care News,  "At issue is whether a False Claims allegation automatically fails when the government continues to approve services or pay for products after learning of alleged infractions. "

Any healthcare revenue cycle professional knows that allegations or initial audit results alone don't put a stop to payment of claims by Medicare or Medicaid. If that were the case, providers who ultimately prevail in their disputes and found innocent of wrong-doing could have a hollow victory if the process ultimately bankrupted their organization. Claims payment is automated, very few claims are reviewed by an actual person before payment unless an organization is on the rare pre-payment review or the claim fails for a technical or coding reason. The operational realities of how claims are paid mitigates the effectiveness of the argument that any claim paid by the Federal or a State government after an investigation is initiated or allegations are put forth is 'approval' of the misdeed.