Payment Strategies
Medicare Changes That You May Not Know Kathleen D. Schaum, MS The eyes and ears of all qualified healthcare professionals (QHPs) were focused on Washington, DC, the week of April 13, 2015. Then, finally it happened: the Congress and Senate voted for and President Obama signed into law on April 16, 2015, the act (Medicare Access and CHIP Reauthorization Act of 2015 [MACRA]) that permanently reformed the Medicare payment system for QHPs. By now, readers should know that the QHP Medicare allowable rates that were effective on January 1, 2015, have been extended through June 30, 2015. The rates will increase by 0.5% on July 1, 2015, through December 15, 2015. Year after year, the new payment system will continue to place more and more emphasis on value rather than volume. I will share more about this very important shift in future Payment Strategies columns. For now, let’s focus on some Medicare changes in this new law that wound care professionals may not know, but may pertain to you, to your patients, and to the Medicare Administrative Contractor (MAC) that processes your Medicare claims.
CHANGES PERTAINING TO WOUND CARE PROFESSIONALS The MACRA has extended the Medicare Part B therapy cap exceptions process through December 31, 2017. Because this exceptions process was scheduled to expire on March 31, 2015, therapists should be thankful for MACRA. In addition, the new law gives the Department of Health and Human Services (HHS) the authority to replace the manual medical review process for therapy services with a new medical review process. The MACRA states that HHS may use medical review factors, such as The therapy provider has had a high claims denial percentage for therapy services or is less compliant with applicable requirements. The therapy provider has a pattern of billing for therapy services that is aberrant compared with peers or otherwise has questionable billing practices, such as billing medically unlikely units of services in a day. The therapy provider is newly enrolled or has not previously furnished therapy under Medicare. The services are furnished to treat a type of medical condition. The therapy provider is part of a group that includes another therapy provider. Prior to MACRA, physicians were required to document that patients had a face-to-face encounter with physicians, nurse practitioners, physician assistants, or clinical nurse
specialists during the 6-month period before an order was written for durable medical equipment. The MACRA now allows the documentation of face-to-face encounters not only by physicians, but also by the nurse practitioners, physician assistants, or clinical nurse specialists who actually had the faceto-face encounter with the patients. Wound care QHPs should find this relaxed documentation requirement more conducive for expedient patient care. The HHS has been preparing for the ‘‘Two Midnight’’ rule that states that inpatient hospital admissions are considered appropriate only when the physician expects the beneficiary to require a stay that crosses at least 2 midnights, and admits the beneficiary to the hospital based on that expectation. The Two Midnight rule generally denies coverage of care expected to require less than a 2-midnight inpatient hospital stay. The MACRA permits the HHS to continue ‘‘probe and educate’’ medical review activities to determine the appropriateness of the inpatient admission under the Two Midnight rule through September 30, 2015. In addition, Recovery Audit Contractors may not conduct postpayment patient status reviews related to the Two Midnight rule until September 30, 2015. Then effective October 1, 2015, HHS will begin applying the ‘‘Two-Midnight’’ rule in making payment determinations and in reviewing claims. Wound care professionals who admit patients to inpatient hospitals should carefully read and understand the Two Midnight rule and implement it in their decision making for inpatient admissions before September 30, 2015. Many wound care professionals who perform surgical procedures assigned to 10- and 90-day global surgical payment packages were concerned about the 2015 Medicare Physician Fee Schedule (MPFS) Final Rule that announced the transition of all global surgical packages to 0-day global periods. The MACRA addressed surgeons’ concerns by blocking that portion of the MPFS Final Rule and by mandating the following to begin no later than January 1, 2017: The HHS shall periodically collect information (the number and level of medical visits furnished during the global period and other items and services related to the surgery and furnished during the global period) from a representative sample of physicians. The Office of Inspector General (OIG) will audit a sample of this reported information to verify its accuracy.
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 6
250
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
WWW.WOUNDCAREJOURNAL.COM
Payment Strategies
Beginning in 2019, the HHS shall use the reported information and other available data to improve the accuracy of valuation of surgical services. Note: The MACRA does not prevent HHS from revaluing misvalued codes for specific surgical services or assigning values to new or revised codes for surgical services.
providers of services and suppliers that have the highest rate
of improper payments, providers of services and suppliers that have the greatest
total dollar amount of improper payments, items and services furnished in the region that have the highest
rates of improper payments, items and services furnished in the region that are responsible
CHANGES PERTAINING TO MACS
for the greatest total dollar amount of improper payments, and
Prior to MACRA, MAC contracts were awarded for 5-year terms. After MACRA, the MAC contract term will be 10 years. This new term length applies to MAC contracts in effect on April 16, 2015, and to contracts signed after that date. In addition, the HHS must make the performance of each MAC (regarding performance requirements and measurement standards) publicly available. Wound care professionals often complained when they had to get used to new MACs every 5 years. This extension of MAC contracts should provide the opportunity for wound care professionals to develop better working relationships with the MAC that processes their claims and writes Local Coverage Determinations pertinent to their work. The MACRA requires each MAC to implement an ‘‘improper payment outreach and education program’’ for providers and suppliers. The MACs are expected to accomplish this mandate through outreach, education, training, and technical assistance, or other activities, such as a list of providers’ or suppliers’ most frequent and expensive payment errors over the last quarter, specific instructions regarding how to correct or avoid such errors in the future, a notice of new topics that have been approved for audits conducted by recovery audit contractors, specific instructions to prevent future issues related to such new audits, and other information determined appropriate by HHS. The MACRA states that the MACs shall give priority to activities that will reduce improper payments that are 1 or more of the following: are for items and services that have the highest rate of improper payment are for items and services that have the greatest total dollar amount of improper payments are due to clear misapplication or misinterpretation of Medicare policies are clearly due to common and inadvertent clerical or administrative errors are due to other types of errors that HHS determines could be prevented through activities under the program The MACs will receive from HHS a complete list of the types of improper payments identified by recovery audit contractors such as
other information that HHS determines would assist the
WWW.WOUNDCAREJOURNAL.COM
contractor in carrying out the program. The HHS is required to establish and maintain procedures for using claim processing edits, updating eligibility information to improve provider accessibility, and conducting recoupment activities through Recovery Audit Contractors to ensure that Medicare payment is not made for items and services furnished to incarcerated individuals, individuals not lawfully present in the United States and not eligible for Medicare coverage, and deceased individuals. The MACRA emphasizes the government’s concern about these wrongful Medicare payments because it specifies that the OIG shall submit to Congress a report about the status of this project no later than 18 months after its enactment.
CHANGES PERTAINING TO MEDICARE BENEFICIARIES The HHS must establish cost-effective procedures to ensure that Medicare Part A and Medicare Part B beneficiaries’ Social Security account numbers are not displayed, coded, or embedded on their Medicare benefit cards. In addition, no other identifier on the card can be identifiable as a Social Security account number (or a derivative thereof). The MACRA is also authorizing HHS to enter the digital age: HHS may consider smart card technology for Medicare beneficiary and provider cards. Caution: Wound care professionals should carefully monitor this part of the law to learn how it may affect their patient identification and tracking processes. The MACRA states that HHS should encourage individuals to report fraud and abuse in the Medicare program by developing a plan to enhance rewards for individuals reporting under the incentive program, including rewards based on information that leads to an administrative action; extend the incentive program to the Medicaid program; and use Senior Medicare Patrols to encourage participation in the incentive program by conducting public awareness and education campaigns. The MACRA mandates that the revised incentive program must be submitted to Congress within 180 days (by October 2015) of MACRA’s enactment.
251
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ADVANCES IN SKIN & WOUND CARE & JUNE 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Medicare Changes That You May Not Know Kathleen D. Schaum, MS The eyes and ears of all qualified healthcare professionals (QHPs) were focused on Washington, DC, the week of April 13, 2015. Then, finally it happened: the Congress and Senate voted for and President Obama signed into law on April 16, 2015, the act (Medicare Access and CHIP Reauthorization Act of 2015 [MACRA]) that permanently reformed the Medicare payment system for QHPs. By now, readers should know that the QHP Medicare allowable rates that were effective on January 1, 2015, have been extended through June 30, 2015. The rates will increase by 0.5% on July 1, 2015, through December 15, 2015. Year after year, the new payment system will continue to place more and more emphasis on value rather than volume. I will share more about this very important shift in future Payment Strategies columns. For now, let’s focus on some Medicare changes in this new law that wound care professionals may not know, but may pertain to you, to your patients, and to the Medicare Administrative Contractor (MAC) that processes your Medicare claims.
CHANGES PERTAINING TO WOUND CARE PROFESSIONALS The MACRA has extended the Medicare Part B therapy cap exceptions process through December 31, 2017. Because this exceptions process was scheduled to expire on March 31, 2015, therapists should be thankful for MACRA. In addition, the new law gives the Department of Health and Human Services (HHS) the authority to replace the manual medical review process for therapy services with a new medical review process. The MACRA states that HHS may use medical review factors, such as The therapy provider has had a high claims denial percentage for therapy services or is less compliant with applicable requirements. The therapy provider has a pattern of billing for therapy services that is aberrant compared with peers or otherwise has questionable billing practices, such as billing medically unlikely units of services in a day. The therapy provider is newly enrolled or has not previously furnished therapy under Medicare. The services are furnished to treat a type of medical condition. The therapy provider is part of a group that includes another therapy provider. Prior to MACRA, physicians were required to document that patients had a face-to-face encounter with physicians, nurse practitioners, physician assistants, or clinical nurse
specialists during the 6-month period before an order was written for durable medical equipment. The MACRA now allows the documentation of face-to-face encounters not only by physicians, but also by the nurse practitioners, physician assistants, or clinical nurse specialists who actually had the faceto-face encounter with the patients. Wound care QHPs should find this relaxed documentation requirement more conducive for expedient patient care. The HHS has been preparing for the ‘‘Two Midnight’’ rule that states that inpatient hospital admissions are considered appropriate only when the physician expects the beneficiary to require a stay that crosses at least 2 midnights, and admits the beneficiary to the hospital based on that expectation. The Two Midnight rule generally denies coverage of care expected to require less than a 2-midnight inpatient hospital stay. The MACRA permits the HHS to continue ‘‘probe and educate’’ medical review activities to determine the appropriateness of the inpatient admission under the Two Midnight rule through September 30, 2015. In addition, Recovery Audit Contractors may not conduct postpayment patient status reviews related to the Two Midnight rule until September 30, 2015. Then effective October 1, 2015, HHS will begin applying the ‘‘Two-Midnight’’ rule in making payment determinations and in reviewing claims. Wound care professionals who admit patients to inpatient hospitals should carefully read and understand the Two Midnight rule and implement it in their decision making for inpatient admissions before September 30, 2015. Many wound care professionals who perform surgical procedures assigned to 10- and 90-day global surgical payment packages were concerned about the 2015 Medicare Physician Fee Schedule (MPFS) Final Rule that announced the transition of all global surgical packages to 0-day global periods. The MACRA addressed surgeons’ concerns by blocking that portion of the MPFS Final Rule and by mandating the following to begin no later than January 1, 2017: The HHS shall periodically collect information (the number and level of medical visits furnished during the global period and other items and services related to the surgery and furnished during the global period) from a representative sample of physicians. The Office of Inspector General (OIG) will audit a sample of this reported information to verify its accuracy.
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 6
250
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
WWW.WOUNDCAREJOURNAL.COM
Payment Strategies
Beginning in 2019, the HHS shall use the reported information and other available data to improve the accuracy of valuation of surgical services. Note: The MACRA does not prevent HHS from revaluing misvalued codes for specific surgical services or assigning values to new or revised codes for surgical services.
providers of services and suppliers that have the highest rate
of improper payments, providers of services and suppliers that have the greatest
total dollar amount of improper payments, items and services furnished in the region that have the highest
rates of improper payments, items and services furnished in the region that are responsible
CHANGES PERTAINING TO MACS
for the greatest total dollar amount of improper payments, and
Prior to MACRA, MAC contracts were awarded for 5-year terms. After MACRA, the MAC contract term will be 10 years. This new term length applies to MAC contracts in effect on April 16, 2015, and to contracts signed after that date. In addition, the HHS must make the performance of each MAC (regarding performance requirements and measurement standards) publicly available. Wound care professionals often complained when they had to get used to new MACs every 5 years. This extension of MAC contracts should provide the opportunity for wound care professionals to develop better working relationships with the MAC that processes their claims and writes Local Coverage Determinations pertinent to their work. The MACRA requires each MAC to implement an ‘‘improper payment outreach and education program’’ for providers and suppliers. The MACs are expected to accomplish this mandate through outreach, education, training, and technical assistance, or other activities, such as a list of providers’ or suppliers’ most frequent and expensive payment errors over the last quarter, specific instructions regarding how to correct or avoid such errors in the future, a notice of new topics that have been approved for audits conducted by recovery audit contractors, specific instructions to prevent future issues related to such new audits, and other information determined appropriate by HHS. The MACRA states that the MACs shall give priority to activities that will reduce improper payments that are 1 or more of the following: are for items and services that have the highest rate of improper payment are for items and services that have the greatest total dollar amount of improper payments are due to clear misapplication or misinterpretation of Medicare policies are clearly due to common and inadvertent clerical or administrative errors are due to other types of errors that HHS determines could be prevented through activities under the program The MACs will receive from HHS a complete list of the types of improper payments identified by recovery audit contractors such as
other information that HHS determines would assist the
WWW.WOUNDCAREJOURNAL.COM
contractor in carrying out the program. The HHS is required to establish and maintain procedures for using claim processing edits, updating eligibility information to improve provider accessibility, and conducting recoupment activities through Recovery Audit Contractors to ensure that Medicare payment is not made for items and services furnished to incarcerated individuals, individuals not lawfully present in the United States and not eligible for Medicare coverage, and deceased individuals. The MACRA emphasizes the government’s concern about these wrongful Medicare payments because it specifies that the OIG shall submit to Congress a report about the status of this project no later than 18 months after its enactment.
CHANGES PERTAINING TO MEDICARE BENEFICIARIES The HHS must establish cost-effective procedures to ensure that Medicare Part A and Medicare Part B beneficiaries’ Social Security account numbers are not displayed, coded, or embedded on their Medicare benefit cards. In addition, no other identifier on the card can be identifiable as a Social Security account number (or a derivative thereof). The MACRA is also authorizing HHS to enter the digital age: HHS may consider smart card technology for Medicare beneficiary and provider cards. Caution: Wound care professionals should carefully monitor this part of the law to learn how it may affect their patient identification and tracking processes. The MACRA states that HHS should encourage individuals to report fraud and abuse in the Medicare program by developing a plan to enhance rewards for individuals reporting under the incentive program, including rewards based on information that leads to an administrative action; extend the incentive program to the Medicaid program; and use Senior Medicare Patrols to encourage participation in the incentive program by conducting public awareness and education campaigns. The MACRA mandates that the revised incentive program must be submitted to Congress within 180 days (by October 2015) of MACRA’s enactment.
251
&
ADVANCES IN SKIN & WOUND CARE & JUNE 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
