Improving patient outcomes while maintaining physician decision making and practice efficiency is key to success in the growing health care arena. Innovation is the ability to see change as an opportunity to create new value, instead of a threat to what we find comfortable. It is clear that the Center for Medicare and Medicaid Services (CMS) is embracing the importance of innovation in the way we deliver health care.
In November 2018, the 2019 Physician Fee Schedule and Quality Payment Program was released by CMS with changes effective January 1, 2019. This is the time for providers to definitely keep their eyes open to utilizing mHealth, and telehealth services. mHealth is also known as mobile health, and is a general term for the use of mobile phones and other wireless technology in medical care to educate consumers about preventive healthcare services as well as for disease surveillance, chronic disease management, treatment support, epidemic outbreak tracking. The release of the program is a sign that the agency is in favor of expanding the implementation of technology in providing medical care. The updated mHealth codes are:
On November 1, 2018, a federal court judge in the U.S. District Court for the District of Columbia granted a motion for summary judgment in favor of the American Hospital Association (AHA) ordering the U.S. Department of Health and Human Services (HHS) to clear the Medicare appeal backlog by fiscal year (FY) 2022. If you have not been following this litigation, the AHA initially filed suit in 2014 against the Secretary of the U.S. Department of Health and Human Services (HHS) requesting an order from the court mandating the Office of Medicare Hearings and Appeals (OMHA) within HHS to comply with its statutory deadlines (i.e. to issue a decision within 90 days). Following brief review by the U.S. Court of Appeals and upon the case being before the district court for a third time, the case has finally reached a resolution.
In short, HHS agreed that due to recent funding, compliance is possible within four years. Accordingly, the judge set the following deadlines for HHS and OMHA:
Over the past several months, the Centers for Medicare & Medicaid Services (CMS) has taken a number of steps that show an awareness of the regulatory burden placed upon participants in the government’s health care programs, and even some willingness to consider reducing those burdens. While it remains to be seen whether the recent proposals will have measurable results, the following actions can still be viewed with guarded optimism.
Proposed Changes to Medicare
In July, 2018, CMS proposed significant changes to Medicare, to be included in rules that take effect in 2019. These changes cover physician fee schedules, streamlining Evaluation & Management (E&M) billing, advancing “virtual care,” decreasing drug costs, revising the MIPS program and establishing the MAQI demonstration project. The agency also asked for comments on price transparency issues.
The transition from paper medical records to electronic medical records has brought with it many conveniences and some unintended consequences. One example of an unintended consequence is cloning in the medical record. Cloning is copying and pasting previously recorded information from a prior patient note into a new patient note.
Providing quality medical care is only one part of the job. Appropriately documenting that care in order to be paid for your efforts is another. And while medical professionals are trained at length to provide care, hardly any are aware of the potential pitfalls associated with improper documentation.
In late 2015, CMS advised that cloning “is a problem in health care institutions that is not broadly addressed.” CMS specified that cloning records may indicate fraud, waste and abuse in inquiries and audits and that each part of a “medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter.”
In 2012, the American Hospital Association (AHA) along with three member hospitals filed a lawsuit against the U.S. Department of Health and Human Services (HHS) for the agency’s failure to meet the 90 day decision requirement at the Administrative Law Judge (ALJ) level known as the Office of Medicare Hearings and Appeals (OMHA). Through the years, the case has moved back and forth between a federal district court and federal appeals court in the District of Columbia. Most recently in March, a federal district court judge ordered the AHA to expand on its suggestions it has made over the course of its litigation for how HHS can clear the ever-growing backlog and additionally, explain why the current procedures are insufficient.
In CMS’ latest “MLN Connects” newsletter, the agency discusses the Comprehensive Error Rate Testing (CERT) program and the top five documentation errors committed by providers. Providers should pay close attention when CMS releases these types of notices. If selected for CERT review, providers are subject to potential action such as post-payment denials, payment adjustments, or other actions depending on the results of the review. Therefore, providers should ensure they fully understand Medicare’s documentation requirements and how to meet these demands.
Aside from the half million already pending before the Office of Medicare Hearings and Appeals (OMHA), OMHA indicates that it receives more appeals each year than its total annual adjudication capacity and has hit its maximum limits given their current resources. With these numbers, the current estimated wait time is 3 years for an Administrative Law Judge (ALJ) to process an appeal. Though recent developments in the litigation involving the U.S. Department of Health and Human Services (HHS) and American Hospital Association (AHA) offered little hope for a resolution, OMHA’s implementation of new settlement initiatives may present a better strategic option for appellants.
Ever since the Centers for Medicare & Medicaid Services (“CMS”) announced its DMEPOS Competitive Bidding Program there has been outcry from both providers and consumers. Particularly with respect to Competitive Bidding for the National Mail-Order Diabetic Testing Supplies Program (“National Mail-Order Program” or “Program”), which took effect on July 1, 2013, there has been a concern about the Program’s sustainability and potential for negative implications to beneficiaries. This is largely due to the low reimbursement rates, as set by the bid winning providers, and the possible spillover effect to the Medicare Part B beneficiaries’ access to quality supplies and services. While CMS had safeguards in place when the Program was implemented, many of the regulations have gone largely unenforced. Change is on the horizon as CMS strives to better police its own Program, but is it too little, too late?
In 2011, prior to the implementation of the National Mail-Order Program, CMS tested Competitive Bidding for diabetic testing supplies in nine geographical regions. In these test markets, the payment rates for a vial of test strips were reduced from $34 to $14. CMS’ goal with Competitive Bidding is to reduce costs to the Medicare Trust Fund and beneficiaries, as well as to curb fraud, waste and abuse in the industry. Wanting to ensure that the intentions of the Program were being fulfilled without repercussions, CMS conducted a study on the nine geographical test regions. In its 2012 report CMS stated that there were no negative consequences to the beneficiaries as a result of the Competitive Bidding Program.
Providers need to comply with all the Medicare ‘red tape’ but need not let fear of non-compliance inhibit their practice from offering Durable Medical Equipment Prosthetics & Orthotics Supplies (“DMEPOS”) to Medicare beneficiaries.
Here’s an overview of the steps providers need to take to enroll as a supplier of DMEPOS with Medicare to be eligible for Part B coverage and reimbursement:
Medicare claims are processed by organizations (i.e. Medicare Administrative Contractors (“MACs”)) that contract with the Centers for Medicare & Medicaid Services (“CMS”) to act as liaisons between the Medicare program and providers and suppliers. As CMS continues to evolve its enforcement strategies to reduce fraud and abuse in the system, post payment reviews utilizing statistical sampling still remain as one of its key methods. These reviews are conducted not just by MACs but also by Zone Program Integrity Contractors (“ZPICs”). When a review is completed, providers and suppliers often face large extrapolated overpayment amounts based on the analysis of a small sample of claims. Therefore, providers and suppliers need to understand the process and most importantly, how to effectively navigate the system.
ZPICs are a part of Medicare’s integrity program and took the place of Program Safeguard Contractors (“PSCs”) that operated with the same goal in the past. ZPIC reviews initiate in various ways such as from whistleblower complaints, through ZPIC investigations (e.g. using data mining), and from referral from the Office of Inspector General (“OIG”).
Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.