Congress on New Year’s Day passed the “American Taxpayer Relief Act of 2012”. The legislation delays for one year a planned cut in Medicare payments for physicians.

For physicians providing multiple therapy services on or after 4/1/13, the 25 percent multiple procedure payment reduction is increased to 50 percent.

To view changes in office visit allowables in your state – click here.

 

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

The Office of Inspector General recently published a report entitled “Coding Trends of Medicare Evaluation and Management Services.”

According to the OIG report “E/M services have been vulnerable to fraud and abuse”.

Office visits 99211 through 99213 all declined in percentage of frequency. 99214 and 99215 both increased. 99214 increased an astounding fifteen percent (15%). 

 

 

 

 

 

 

 

 

 

 

 

 

Similar trends held true across 13 different categories of E/M services.

The jump from 99213 to 99214 yielded a handsome increase in compensation. In 2010, Medicare paid on average $97.35 for a 99214 visit, which is 50% more than the $64.80 for a 99213.

As a result of this study, OIG turned the names of 1,700 physicians over to CMS and suggested review.

The OIG states that it did not determine whether physicians who chose more 99214’s and other higher-level E/M codes in 2010 billed Medicare inappropriately or fraudulently. That line of inquiry, it says, will be the focus of future reports.

The following month (June 2012) the OIG issued a Memorandum Report – Use of Electronic Health Record Systems in 2011: Among Medicare Physicians Providing Evaluation and Management Services.

The survey concluded that physicians do not trust their EHR’s to assign billing codes. Of the 2,000 physicians surveyed, 88% manually assign the codes for E&M services and the remaining 12% use professional billers to do so.

The message is crystal-clear, OIG has specifically targeted billing fraud perpetuated by reliance on EHR coding/documentation. The Problem with EHR’s and Coding – Medical Economics. 

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would increase payments to family physicians and other practitioners providing primary care services.

Most of this increased reimbursement would result from a separate payment that Medicare would make to physicians for coordinating a patient’s care for the first 30 days after discharge from a hospital, skilled nursing facility, or certain outpatient services. The fee will have its own procedure code.

Under CMS’ proposal, Medicare pay would increase by:

• Family Physicians       7%
• Internists                       5%
• Geriatricians                 4%

To pay for these raises, CMS said that it has to lower reimbursement for other clinicians to achieve budget neutrality.

• Radiation Oncologists              -15%
• Radiology                                       -4%
• Anesthesiology                             -3%
• Cardiology                                     -3%
• Interventional Radiology             -3%
• Vascular Surgery                          -3%
• Pathology                                       -2%
• Urology                                           -2%
• Neurosurgery                                -1%

No anticipated change in Medicare reimbursement for:

• Allergy/Immunology
• Gastroenterology
• General Surgery
• Plastic Surgery
• Rheumatology

The proposed Medicare fee schedule will be published in the Federal Register on July 20. CMS will accept comments on the proposal until September 4, and the agency will issue a final fee schedule by November 1.

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

Contracts may have an auto-update clause or state “current year Medicare.” How do these updates effect your reimbursement? Some payers update four times a year or more.

Many payers base their fee schedules on Medicare. If that is the case, then the next questions are:

1.      What Year Medicare?
2.      What %?
3.      What Local / Region?

Many payers also update code ranges that have been revised with new code descriptions and thus affect payment. Offices rarely look at how these codes affect their bottom line; costing you big dollars. 

Payers often base their schedules on “lesser of” language, where typically the payer will agree to reimburse the fee schedule, or your physician office’s billed charge, whichever is lesser. In other words, you have the potential to “under-bill” – disastrous!

One of the common mistakes practices make is accepting the payment given without verifying the allowable. Knowledge of the fee schedules also allows staff to ensure proper collection of payment at the time of service.

From a business standpoint, isn’t the final outcome of your hard work accurate payment?

Know Your Contracted Rates – It’s Just That Simple!

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

Physicians received the wrong payment for nearly 1 of every 10 claims (9.5%), and there was a 69% increase in denied claims last year. Imagine your credit card bill – 1 out of 10 charges are incorrect!

The AMA publishes an annual report card of the claims revenue cycle activities of the major commercial health insurers and Medicare. The NHIRC provides metrics on the timeliness, transparency and accuracy of claims processing of these payers in an effort to educate physicians and the public, and to reveal opportunities for improvement.

The review was based on a claims processing firm’s random sampling of data obtained for the AMA from Aetna, Anthem Blue Cross Blue Shield, Cigna, Health Care Service Corporation, Humana, Regence, and UnitedHealthcare, as well as Medicare.

The firm examined about 1 million claims for nearly 2 million medical services submitted in February and March 2012 by more than 380 physician practices in 79 medical specialties in 39 states. The government’s Medicare program was the only payer that provided both a reason and some additional comments for all denied claims.

National Health Insurer Report Card

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

According to a 2012 Medscape Physician Compensation Report physician income declined in general, although the top-earning specialties remained the same as in Medscape’s 2011 survey.

For employed physicians, compensation includes salary, bonus, and profit-sharing contributions. For partners, compensation includes earnings after tax-deductible business expenses but before income tax. Compensation excludes non-patient-related activities (eg, expert witness fees, speaking engagements, and product sales).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medscape Physician Compensation Report: 2012 Results

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

Beginning June 1, 2012 Blue Shield of California will update its “Professional Allowances”.

These allowances use a combination of methodologies and factors: clinician input, type of service, geography and regional factors, relative value units, the market, and other industry sources.

Blue Shield will continue reimbursing for inpatient (CPT® Codes 99251-99255) and outpatient CPT® Codes 99241-99245) consultations.

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

The Affordable Care Act seeks to increase access to high-quality, affordable health care for all Americans. To that end, the law, in Section 3011, requires the Secretary of the Department of Health and Human Services (HHS) to establish a National Strategy for Quality Improvement in Health Care (the National Quality Strategy) that sets priorities to guide this effort and includes a strategic plan for how to achieve it.

National Quality Strategy – this NQS is a value-based / risk-based payment model to promote: higher quality, lower cost, and better health.

Value-based, risk-based equals budget-based and when you’re dealing with budgets you should be looking at projected and actual budgets.

Why Risk Adjustment – to eliminate cherry picking patients and physician payment impact. You must be proactive in obtaining systems that possess the greatest degree of accuracy. You must also ensure the accuracy and methodology of health plans risk adjustment.

Back to the budgets – money going out / money coming in; first the money going out: determining your cost of doing business, Baseline Costs

Money coming in; you’ve heard it all by now, bottom line is you are going to get paid x for doing y. The following are some key elements to consider with each model. These are not meant to be all-inclusive, but you are likely to see one of these. Remember x for y, keep it simple, it’s your money.

Payment Option Models

FFS fee-for-service and related issues

• Variations
• Payer-specific edits
• Pricing rules: multi-procedure rules and updates

PFP pay-for-performance programs

• How did the health plan establish quality / cost efficiency targets?
• Measuring patient satisfaction and incorporating into quality scores

Capitation

• Mid-90’s failure but we certainly have new / better technology now

Bundled Payments

• How will these bundled payments be structured?
• Bundle definition, time, condition, CPT code?
• Items and services attributed to physician?
• Payments apportioned among participants?
• Payments made to single entity or virtual bundling?

Withholds and Risk Pools

• What will the withhold amount be?
• Timing of Remittances (problem in 90’s)

Federal Regulations

• Who, how, and when will the risk pools be audited?

If you haven’t heard of: Division of Financial Responsibility (DOFR) dealing with respective financial responsibilities, it’s worth looking into at http://www.iha.org/

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

The change only affects providers whose first incentive payment year is 2011, since they are the only providers who would be subject to Stage 2 regulations in 2013 had the delay not been implemented, everyone was already entitled to 2 years of meaningful use at Stage 1.

Those provider’s who have attested to Stage 1 in 2011, now can earn 3 years of incentives under the less stringent requirements of Stage 1 (only if they are willing to forego their Medicare ePrescribing bonuses). Foregoing ePrescribing bonuses can be very costly for high-revenue, high-volume Medicare providers – be very careful here!

This announcement has no impact on eligible hospitals that had not already attested in 2011, only eligible providers who have not yet attested.

It seems counterintuitive that a delay in a deadline would encourage faster adoption rates by providers. Here is how the incentive is intended to work:

Prior to the Delay

• If a provider completed Stage 1 Meaningful Use in 2011, they would have to complete Stage 2 Meaningful Use by 2013.
• If a provider completed Stage 1 Meaningful Use in 2012, they would have to complete Stage 2 Meaningful Use by 2014.

After the Delay

• Stage 1 demonstration and attestation would continue through 2013.
• Stage 2 would start in 2014.
• Stage 3 would start in 2015.

With the revised timing, providers will still receive the same payments as originally planned. Instead of 2013, however, early entrants will have to wait to attest and receive payments for Stage 2 in 2014.

HHS claims to be working towards a realistic balance between achieving desired results of EHR implementation with the practical realities that providers are facing in implementing EHR systems. Only time will tell.

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).

Published February 9, 2012 – Wall Street Journal | Health

Last month, Wellpoint and Aetna outlined their new compensation plans.  Now, UnitedHealth, the largest U.S.health insurer, becomes the latest carrier to say it is overhauling its fees for medical providers.

UnitedHealth, like other insurers, is targeting the traditional system that pays hospitals and doctors for each service provided, rewarding them for more care but not necessarily better care. Under the new plan the carrier is rolling out, part of medical providers’ compensation could be tied to goals such as avoiding hospital readmissions and ensuring patients get recommended screenings.

UnitedHealth has been trying such efforts on a more limited scale, but now the company says it plans to roll out new contracts nationwide that could include financial rewards for care the company considers high-quality and efficient, and in some cases potentially withhold expected increases if certain standards aren’t met. UnitedHealth has more than 5,500 hospitals and 550,000 doctors in its network.

Among the measures that might be tied to pay are, for hospitals, rates of readmissions, use of radiology services, mortality rates for certain conditions, and hospital-acquired infection rates, as well as patients’ satisfaction. For doctors, the goals might involve their rates of inpatient admissions and emergency-room use, the total cost of patients’ care, and quality measures such as the share of patients getting recommended screenings. UnitedHealth also said it could offer “clinical integration” fees for providers participating in patient-centered medical homes.

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CPT® codes and descriptions are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).