Two Significant Healthcare Laws Celebrate Anniversaries Despite                                   Their Initial and Ongoing Adversaries

Healthcare lawOn July 30, 1965, President Lyndon B. Johnson signed into law legislation that established the Medicare and Medicaid programs. For 50 years, these two programs have been protecting the health and well-being of millions of American families. Enacted under Title VIII of the Social Security Act, Congress created Medicare for Americans beginning at age 65. Medicare also authorized coverage for Americans who became disabled. The Affordable Care Act (ACA) commonly known as Obamacare, is a United States (U.S.) federal statute signed into law by President Barack Obama on March 23, 2010. The law provides health insurance to any U.S. citizen through newly formed State agencies called insurance exchanges. According to the White House, over 10 million Americans have signed up for coverage under the ACA statute. Both laws were not passed without brisk debates from adversaries lead by politicians, providers of care, and the populist.

Before Medicare was law, many uninsured seniors lived under the fear of bankruptcy if they became ill and needed expensive medical service. When the Medicare bill was being debated, the usual conservative pundits argued that Medicare would ruin our “wonderful medical service.” A future President and strong conservative, Ronald Reagan lent his voice to an 11-minute record album called “Ronald Reagan Speaks out against Socialized Medicine.” It delivered a strong warning against the dangers of government involvement in health care. “One of the traditional methods of imposing statism or socialism on a people has been by way of medicine,” Reagan says. “It’s very easy to disguise a medical program as a humanitarian project.” He calls on those listening to his record to contact their Congressman and oppose the legislation.1 Some swore that Medicare would be the end of good patient care. Today, the nation’s seniors, most politicians, and even providers praise Medicare coverage. Seniors hope for expanded services to cover other medical and dental needs. They are aware of the low administrative costs and excellent care that they receive under Medicare.

The story of enacting Medicare is one of persistent political struggle. There was growing recognition in the late 1950s and early 1960s of the need for federal action to help meet the high cost of healthcare for the Nation’s elderly. But there were sharply different views about how to provide medical coverage. One must also realize that as with any point in time, politics and policy, do not happen in a vacuum. In the early 1960s, the tension between states’ rights versus direct federal provisions for citizen protections was playing out on a separate track in the debate over civil rights. That debate culminated with enactment of the Civil Rights Act of 1964. Title VI of that act provided that “no person in the United States shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program or activity receiving federal assistance.” 2 By providing federal funds for healthcare to the elderly on the heels of the Civil Rights Act, Medicare played a major role in desegregating every hospital in the U.S.

Medicare, Medicaid and the ACA were game changers for health law, politics, and policy because they brought the federal government—which means not only Congress but the federal courts and the executive branch—squarely into the health care arena for the first time. The ACA, acclaimed by many to be the most significant health care legislation since the passage of Medicare, brought intense debate and finally a decision to implement the law by the U.S. Supreme Court.

By affirming in a 6-3 vote, the Supreme Court ruled in favor of the U.S. government in King v. Burwell in a June 25 opinion that “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”
The law, which requires nearly all citizens of the United States to be covered by health insurance, gives subsidies to citizens earning under a certain amount of money in the form of tax breaks via exchanges, which are created by the states or, in the absence of a state exchange, by the federal government. Plaintiffs had argued that a short passage in one section of the law regarding the application of federal subsidies as tax breaks – “exchange established by the state” – made clear that the subsidies for federally created exchanges should be stopped – which many observers predicted would throw Obamacare into chaos.

The Obama administration argued that the rest of the 19,000-plus-page law made clear by context that the federal exchanges were intended to fill in when the states did not make their own. “Petitioners’ arguments about the plain meaning of [ACA’s] Section 36B are strong,” says Chief Justice Roberts’ in the majority opinion. “But while the meaning of the phrase ‘an exchange established by the state under [42 U. S. C. §18031]’ may seem plain ‘when viewed in isolation,’ such a reading turns out to be ‘untenable in light of [the statute] as a whole.'”
In his dissent, Justice Antonin Scalia stated that the question raised by the plaintiff is “so obvious there would hardly be a need for the Supreme Court to hear a case about it” and goes on to claim that the majority has engaged in “somersaults of statutory interpretation.” Scalia grumbled in closing that his colleagues “had concluded that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.” 3
President Obama in his comments to the public addressing the Supreme Court decision pronounced “that the ACA is here to stay.” 4

The Centers for Medicare and Medicaid Services (CMS) plan to mark the golden anniversary of the Medicare and Medicaid programs by recognizing the ways in which these programs have transformed the nation’s health care system over the past five decades. Hopefully, in another 45 years they will be recognizing the same type of transformation with the ACA.

1 https://www.nasi.org/discuss/2015/02/covered-docs-labor-escalate-fight-over-health-plan-elderly
2 https://www.nasi.org/sites/default/files/research/med_report_reflections.pdf
3 http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf

4 https://www.whitehouse.gov/healthreform

View this article and others at Miramedgs.com

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog. He serves as the Vice President of Global Services for MiraMed, a global healthcare Business Processing Outsourcing services company. Phil has 25 years of experience in healthcare as an industry thought leader, strategist, solution provider, author and featured speaker. In this blog, you will read about important industry updates, strategies for
improving financial performance, and commentary that challenges the status quo. 

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Who Will Throw up The White Flag First?

ICD-10 white flagIt has been going on longer than the Twenty-Year War that began in 1475. The World Health Organization (WHO) released in 1993 the International Classification of Diseases, Tenth Edition (ICD-10). Shortly thereafter, the Healthcare Financing Administration (now the Centers for Medicare and Medicaid Services (CMS)) began moving forward to prepare for its implementation it in the United States (U.S.). Like the Twenty-Year War and many others bravely fought throughout history, the ICD-10 conflict has really consisted of a lot of little battles, which are, or will be, subsumed as one in the archives.

A year ago the healthcare industry was reeling from the unexpected delay to the implementation of ICD-10. The surprise attack, which brought on the last minute change in the implementation date, was slipped into legislation to provide a temporary patch to the sustainable growth rate (SGR) and passed within a few days, without ample time for the other side to rally their troops. While this hurdle was difficult for advocates of ICD-10 to deal with, it had followed many previous small battles to permanently disarm the change to ICD-10.

The significant backlash from physicians’ groups and organized medicine had successfully challenged, the Health and Human Services (HHS) October 1, 2011 proposed an implementation date to replace ICD-9-CM with ICD-10-CM and ICD-10 PCS. The transition dealine was first pushed back to an October 1, 2013 deadline for adoption. By 2012, the well-funded opposition again forced the deadline to be moved, from October 1, 2013 to October 1, 2014. That battle was followed by The Protecting Access to Medicare Act of 2014, the last minute emergency legislation to provide relief from the SGR. This bill, which contained a provision prohibiting the HHS Secretary from adopting the ICD-10 code prior to October 1, 2015.

Politicians and Presidents from the Oval office to the boardroom of every healthcare organization in the U.S., including the American Medical Association (AMA), the American Hospital Association (AHA), the Medical Group Management Association (MGMA) and the American Health Information Management Association (AHIMA) have remained entrenched to protect, or attack, the October 1, 2015 implementation deadline. In short, the ICD-10’s implementation has been a long, dramatic timeline and one that is, unfortunately, still being contested on the Congressional battlefield.

Despite the “firmness” asserted by CMS of the October 1, 2015 date, the road to the implementation deadline has not been unscathed in 2015. On June 9th, the House of Representatives introduced a bill to allow a two-year ICD-10 “grace period” to help physicians and healthcare providers more effortlessly transition from ICD-9 into ICD-10. Representative Gary Palmer in proposing the bill—Protecting Patients and Physicians Against Coding Act of 2015, H.R. 2652—indicated the intention was to smooth out the code submission process for ICD-10-CM/PCS. The bill calls upon the Secretary of HHS to provide for a two-year grace period during which physicians and other health care providers submitting claims and other documents using ICD-10 to Medicare and Medicaid are not penalized for errors, mistakes, and malfunctions relating to the transition to such a code set.

This is the third ICD-10 related bill introduced into the House within the past five weeks. Early in May, the House proposed a new bill, H.R. 2126, the Cutting Costly Codes Act of 2015, aimed at freezing ICD-10 CM/PCS implementation. The bill, strongly supported by the AMA, intends to prohibit Sylvia M. Burwell, Secretary of HHS, from substituting the currently implemented ICD-9 diagnostic code set with ICD-10. H.R. 2126 additionally mandates the Government Accountability Office (GAO) to execute research on how to best alleviate the financial burden of this decision on healthcare providers. AMA President, Steven J. Stack responding to last year’s implementation delay said, “While the AMA appreciates that physicians have additional time to comply with ICD-10, we continue to have fundamental concerns about ICD-10 and its implementation, which will not be resolved by the extra time. The AMA has long considered ICD-10 to be a massive unfunded mandate that comes at a time when physicians are trying to meet several other federal technology requirements and risk penalties if they fail to do so.”1 A 2014 update of a widely referenced 2008 report by Nachimson Advisors to the AMA estimated the cost for a small practice to implement ICD-10 was in the range of $22,560 to $105,506.2

In direct opposition to the 2014 “controversial” delay and any additional delays in 2015, the AHIMA blasted the AMA cost estimates of ICD-10 implementation. Coming in with a substantially lower cost, the AHIMA research shows a price tag of $1,960 to $5,900 for small practices. Accordingly, AHIMA found that the current evidence suggests that the AMA estimates of the costs and effort associated with ICD-10 implementation for physician offices has been overestimated and that vendors, health plans and physicians have made considerable progress with fewer resources than had been previously estimated.3

It also follows the House’s proposal of the Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-10 bill), H.R.2247 intended to mandate Sylvia M. Burwell, Secretary of the Department of Health and Human Services, to implement additional transparent testing opportunities. The bill sponsored by Representative Black, requires the Secretary to conduct and make available to all participating service providers and suppliers, a comprehensive, end-to-end testing process to assess whether the Medicare fee-for-service claims processing system based on the ICD-10 standard is fully functioning. The Secretary must subsequently certify to Congress whether or not the Medicare fee-for-service claims processing system based on the ICD-10 standard is fully functioning, including additional steps a not-fully-functioning system will take to achieve certification as well as the anticipated time frame for achieving it.4

It has been 16 years since the U.S. version of ICD-10 was completed and five years since publication of the ICD-10 final rule. Every implementation delay has caused providers disruptions, confusion and for many, a lack of trust with CMS and Congress. None of the aforementioned congressional actions address the significant cost the industry has absorbed due to numerous delays of ICD-10. CMS has estimated that the 2014 delay, enacted on April 1 through a legislative act of Congress, has cost the healthcare industry approximately $6.8 billion in lost investments, not including the cost associated with missed opportunities for better health data to improve quality of care and patient safety.

It is difficult to estimate the overall costs incurred by the U.S. Government, payers, providers and vendors throughout the past decade. It’s likely to have exceeded $50 billion, however no one really knows for sure.

As of press time, we are still on track for ICD-10 implementation in October. The transition from ICD-9 to ICD-10 has been fraught with frustrations. Those that seek to delay or permanently kill off the ICD-10 implementation have not yet waved a white flag. Both sides have their armies of advocates and sponsors ready to be heard on Capitol Hill.

To that end, on June 18th the nation’s four largest state medical societies, collectively, the California Medical Association, Florida Medical Association, Medical Society of the State of New York, and Texas Medical Association have written to Andy Slavitt, the Acting Administrator Centers for Medicare & Medicaid Services to ask for help in modifying the ICD-10 transition to reflect the following changes:

– A two-year period during which physicians will not be penalized for errors, mistakes, and/or
malfunctions of the system;
– A two-year period in which physicians will not be subject to RAC audits related to ICD-10
coding mistakes;
– A two-year period during which physician payments will not be reduced or withheld based
on ICD-10 coding mistakes; and
– Advance payments in the event that claims are delayed.

Whether you see yourself or your organization as a champion or a conqueror regarding ICD-10, it is likely both sides will need to “bend the knee” to the reality of a whole new world of healthcare challenges; many far more serious and potentially expensive than the twenty-plus years required to resolve one small piece of the U.S. healthcare industry.

1http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page
2 Ibid.
3http://journal.ahima.org/2014/11/12/cost-of-converting-small-physician-practices-to-icd-10-much-lower-than-reported/
4https://www.congress.gov/bill/114th-congress/house-bill/2247

View this article and others at Miramedgs.com

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog. He serves as the Vice President of Global Services for MiraMed, a global healthcare Business Processing Outsourcing services company. Phil has 25 years of experience in healthcare as an industry thought leader, strategist, solution provider, author and featured speaker. In this blog, you will read about important industry updates, strategies for improving financial performance, and commentary that challenges the status quo. 

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Health Care Transparency Should Be About Strategy, Not Marketing

Health care organizations need to re-think their concept of strategy to thrive in a marketplace driven by competition on value – how well they improve patient outcomes and cut costs. That re-thinking begins with clarifying what the organizations are truly trying to accomplish, and for what “customers,” and how they are going to distinguish themselves from competitors and offer a unique value proposition. Make no mistake – improving value for patients is hard. But as Michael Porter and I write in our recent Perspective article in The New England Journal of Medicine, “Why Strategy Matters Now,” providers are unlikely to succeed if they cannot focus on this goal.

This critical question of organizational goal applies to how providers think about transparency – the growing trend to make their performance data public. What are they trying to accomplish when, for example, they publicize surgical success rates or patient experience data and comments? Are they focused mostly on marketing (aka “reputation management”), or are they trying to improve their actual performance by engaging patients and caregivers with complete and objective data?

The answer is important because the transparency movement will be a game changer. For years, most provider organizations were skeptical about whether “quality” could really be measured, and many resisted public reporting of any performance data or tried to focus their data collection on process measures that they could control. (I make these comments with appropriate humility, having at times pushed as a clinician and health care executive for “translucency” more than transparency in the past.)

To read the rest of the article, go to Harvard Business Review Site

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog. He serves as the Vice President of Global Services for MiraMed, a worldwide healthcare Business Processing Outsourcing services company. Phil has 25 years of experience in healthcare as an industry thought leader, strategist, solution provider, author and featured speaker. In this blog, you will read about important industry updates, strategies for improving financial performance, and commentary that challenges the status quo. 

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icd-10There are so many uncertainties surrounding the ICD-10 transition, it’s helpful when CMS offers information and feedback to help providers understand what they are getting into. If you haven’t seen this yet, I hope it helps to clarify the facts. You’ll find more information at cms.gov – PCS

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Five Facts about ICD-10

To help dispel some of the myths surrounding ICD-10, the Centers for Medicare & Medicaid Services (CMS) recently talked with providers to identify common misperceptions about the transition to ICD-10. These five facts address some of the common questions and concerns CMS has heard about ICD-10:

1. The ICD-10 transition date is October 1, 2015.
The government, payers, and large providers alike have made a substantial investment in ICD-10. This cost will rise if the transition is delayed, and further ICD-10 delays will lead to an unnecessary rise in health care costs. Get ready now for ICD-10.

2. You don’t have to use 68,000 codes.
Your practice does not use all 13,000 diagnosis codes available in ICD-9. Nor will it be required to use the 68,000 codes that ICD-10 offers. As you do now, your practice will use a very small subset of the codes.

3. You will use a similar process to look up ICD-10 codes that you use with ICD-9. Increasing the number of diagnosis codes does not necessarily make ICD-10 harder to use. As with ICD-9, an alphabetic index and electronic tools are available to help you with code selection.

4. Outpatient and office procedure codes aren’t changing.
The transition to ICD-10 for diagnosis coding and inpatient procedure coding does not affect the use of CPT for outpatient and office coding. Your practice will continue to use CPT.

5. All Medicare fee-for-service providers have the opportunity to conduct testing with CMS before the ICD-10 transition.

Your practice or clearinghouse can conduct acknowledgement testing at any time with your Medicare Administrative Contractor (MAC). Testing will ensure you can submit claims with ICD-10 codes. During a special “acknowledgement testing” week to be held in June 2015, you will have access to real-time help desk support. Contact your MAC for details about testing plans and opportunities.

Keep Up to Date on ICD-10 – Visit the CMS ICD-10 website for the latest news and resources to help you prepare.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog. He serves as the Vice President of Global Services for MiraMed, a worldwide healthcare BPO company. MiraMed provides solutions to leading hospitals, health systems, large physician groups and industry partners providing services in the areas of revenue cycle optimization, medical coding, clinical improvement documentation and technology integrations.Phil has 25 years of experience as an industry thought leader, strategist, solution provider, author and featured speaker. He has worked closely with some of the industry’s best and brightest leaders in healthcare finance and revenue cycle operations.

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Money paid

The Association of Healthcare Access Management (NAHAM) promotes best practices, standards and subject matter expertise to their members to influence and promote high quality delivery of Patient Access Services and POS collections.  In early January 2015,

In early January 2015, NAHAM released 22 standard patient access key performance indicators (KPIs) called the NAHAM AccessKeys®.  The AccessKeys are available to NAHAM members and provide a better way to track and measure the performance of patient access.  AccessKeys were created for six key areas: Collections, Conversions, Patient Experience, Process Failure and Resolution, Productivity and Quality.  Prior to the establishment of the NAHAM’s recognized standards, it was difficult to produce an accurate comparative benchmark because patient access departments lacked a level of standardization in terms of definitions and measurements in use at their facility.  The

The NAHAM AccessKeys definitions of what is or isn’t included in certain processes will further assist patient access departments in determining how well various functions are being performed in comparison to other hospitals.

For the past three years, AccuReg has conducted an annual benchmark survey for patient access.  The 2014 Registration Benchmark Survey was just released and it covers patient access topics such as current practices and trends in pre-registration, point-of-service (POS) collections, scheduling, patient portals and registration accuracy.  Based on the survey results, more facilities are pre-registering their patients.  The survey found that 38 percent were now meeting the industry standard goal for hospitals of pre-registering 90 percent or more of scheduled patients.  This was a 15 percent increase from the 2013 results.  The survey results also found that the majority of hospitals pre-register their patients on average three days before the service.

According to AccuReg, two of the most significant differences between the 2013 and 2014 answers are the following:

  • The number of respondents screening and obtaining authorizations rose from 51 percent in 2013 to 65 percent in 2014.
  • The number of respondents that estimate the patient liability and screen for financial assistance increased 12 percent.  In 2013 only 47 percent estimated liability and 2014 showed 59 percent now do that during pre-registration.

With almost half of the respondents now screening for financial assistance in pre-registration, the survey results show that hospitals have geared up to deal with specific aspects of the Affordable Care Act (ACA) regarding high-end deductibles and potential enrollment of patients in Medicaid or another insurance products.

POS collections have now become universally in place at all hospitals; however, most are still struggling with how best to determine the amount to collect.  A variety of tools are in place from third-party vendors insurance verification products to financial estimates of patient’s liability.  By providing the patient with an estimate of what their likely liability is, the patient is more vested in the process and is better informed prior to the service.  As a result of the improvements in pre-registration, verification and POS estimates hospitals have significantly improved their POS collections in the past two years to 40 percent of total collections occurring at POS collections.

With the adoption of NAHAM AccessKeys performance indications, hospitals will have a better means to realign their POS departments and standardize processes.  As a result, performance can only continue to increase.

Article authored by MiraMed, a BPO Outsourcing Services Company

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog. He serves as the Vice President of Global Services for MiraMed, a worldwide healthcare BPO company. MiraMed provides solutions to leading hospitals, health systems, large physician groups and industry partners providing services in the areas of revenue cycle optimization, medical coding, clinical improvement documentation and technology integrations. Phil has 25 years of experience as an industry thought leader, strategist, solution provider, author and featured speaker. He has worked closely with some of the industry’s best and brightest leaders in healthcare finance and revenue cycle operations.

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Patriots Super Bowl 2015Last week we reviewed Health and Human Services (HHS) Secretary Sylvia M. Burwell’s January 26, 2015 announcement on specific goals and a timeline for shifting Medicare reimbursements from the traditional fee-for-service (FFS) model to a quality or value-based model.  The  HHS team is optimistic in achieving its goals, noting in its press release that it has “already seen promising results on cost savings with alternative payment models” through a combined total program savings of $417 million to Medicare due to existing ACO programs.  Moreover, it “expects these models to continue the unprecedented slowdown in health care spending.”1

In Sunday’s Super Bowl game, each team had some predictable plays that delivered and some unexpected but practiced, approaches to score that demonstrate their commitment to being flexible and resourceful.  Whether we realize it or not, HHS has been acquiring quite a playbook of historically proven cost and value moves.

Typically these programs include measures of clinical process and intermediate outcomes (e.g., Healthcare Effectiveness Data and Information Set [HEDIS] or Joint Commission measures), patient safety measures (e.g., surgical infection prevention), utilization (generic prescribing, emergency department use, length of stay, ambulatory care sensitive hospital admissions), patient experience (e.g., Consumer Assessment of Healthcare Providers and Systems survey, Hospital Consumer Assessment of Healthcare Providers and Systems survey) and, to a more limited degree, outcomes (e.g., readmissions, mortality, complications, total cost of care or cost per episode) and structural elements (e.g., Health Information Technology (HIT) adoption or meaningful use of HIT requirements for CMS incentive payments, National Committee for Quality Assurance certification or patient-centered medical home certification, staffing, inspections).  Clinical measures in the ambulatory setting focus heavily on preventive care and management of heart disease and diabetes, while in the hospital setting the focus has been on heart attack, congestive heart failure (CHF), pneumonia and surgical infection prevention.  All of these initiatives are like moving the ball slowly and carefully down the field to get some points on the scoreboard.

Historically safe plays may prove to get the job done but it is often the unusual or new approach that sometimes makes the big payoff.  Of course, the Patriot’s Malcom Butler’s last second interception when the Seahawks tried something different shows that an unusual choice does not always spell success over the proven approach to the goal line.  As HHS sets a 2018 target date, let’s review their scorecard with two innovative programs designed to demonstrate that moving to a quality and value based reimbursement system may result in a future super win for HHS.

HHS announced two wins with the Comprehensive Primary Care (CPC) initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration.  According to HHS, the CPC initiative, in its first year, decreased hospital admissions by two percent and emergency department visits by three percent, contributing to the reduction of expenditures nearly enough to offset care management fees paid by the Centers for Medicare and Medicaid Services (CMS).  The MAPCP Demonstration generated an estimated $4.2 million in savings through the use of advanced primary care initiatives.

With authority from the Affordable Care Act, the CPC initiative is a unique multi-payer partnership between Medicare, Medicaid private health care payers and primary care practices in four states (Arkansas, Colorado, New Jersey and Oregon) and three regions (New York’s Capital District and Hudson Valley, Ohio and Kentucky’s Cincinnati-Dayton region and Oklahoma’s Greater Tulsa region).  This initiative includes providing care management for those at greatest risk; improving health care access; tracking patient experience; coordinating care with hospitals and specialists; and using health information technology to support population health.  Practices receive non-visit based care management fees from the participating payers and the opportunity to share in savings.

In the first year, 492 practices participated, serving about 345,000 Medicare beneficiaries and more than 2.5 million patients overall.  Results from this first year suggest that the primary sources of the savings were reduced rates of hospital admissions and emergency department visits.  With over 90 percent of the practices successfully meeting all first-year transformation requirements, the results are very promising; yet it is the first time we have seen results from this playbook so caution should be used in assessing if this is an initiative that will affect long term cost and quality of care.

The MAPCP Demonstration is a multi-payer initiative in which Medicare is participating with Medicaid and private health care payers in eight advanced primary care initiatives in Maine, Michigan, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island and Vermont.  Unlike CPC, the states convene the participants and administer the initiatives rather than CMS.  Under this demonstration, participating practices and other auxiliary supports (e.g., community health teams) receive monthly care management fees from the participating payers and additional support (e.g., data feedback, learning collaboration, practice coaching).

More than 3,800 providers, 700 practices and 400,000 Medicare beneficiaries participated in the first year.  During the first year, the demonstration produced an estimated $4.2 million in savings.  Also, the rate of growth in Medicare FFS health care expenditures was reduced in Vermont and Michigan, driven largely by reduced growth in inpatient expenditures.  There is less evidence that the state initiatives were able to reduce hospitalization, readmission and emergency department visit rates.  Additional findings in this evaluation period include:

  • The MAPCP payments provided needed support to help practices transform the way they deliver and coordinate care, including use of nurse care managers or care coordinators, restructuring of staff, improvements in patient flow, adoption of health information technology and more frequent staff meetings.
  • Medicare was able to integrate seamlessly with the structure and organization of the eight state initiatives.  Medicare’s participation sent a strong signal about the importance of primary care and the potential of these programs, helping to affirm payer and provider commitments.
  • Although collecting and using data was a recurring challenge, health information systems facilitated the transformation process.

These first-year results illustrate the potential for steady improvements in the participating practices’ advanced primary care capabilities.  CMS anticipates continued improvements as the participating practices deepen and refine their methods of delivering advanced primary care so that patients can continue to receive improved quality and coordination of care.

Yet there is some uncertainty as to how well these payment approaches will work.  A 2014 Rand Corporation study funded by HHS concluded, “We still know very little about how best to design and implement [value-based payment] programs to achieve stated goals and what constitutes a successful program.”2  The report reviewed pay-for-performance models implemented over the past decade, and tempered the improvements cited by HHS with a dose of caution—“improvements were typically modest” and often hard to evaluate.

If the HHS reaches its stated goals, such improvements will be a super win for HHS and the American healthcare system.

Article published by MiraMed. To learn more about: MiraMed.

1The January 26, 2015 HHS Press Release can be found at http://www.hhs.gov/news/press/2015pres/01/20150126a.html
2http://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR306/RAND_RR306.pdf

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and is the Vice President of Global Services for MiraMed, a worldwide healthcare BPO company. MiraMed provides solutions to leading hospitals, health systems, large physician groups and industry partners providing services in the areas of revenue cycle optimization, medical coding, clinical authorization and technology integrations. Phil has 25 years of experience as an industry thought leader, strategist, solution provider, author and featured speaker. He has worked closely with some of the industry’s best and brightest leaders in healthcare finance and revenue cycle operations.

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StateLike many with careers in healthcare delivery or administration, we anxiously listened to each word of President Obama’s 2015 State of the Union address to see what the White House agenda may be for the remainder of his Presidency.  While guarantees of sick days, paid maternity leave, along with the successful battle to control Ebola, and find cures to other deadly diseases, were mentioned, the President’s address seemed light on healthcare, especially considering the turmoil over the past year with the Affordable Care Act (ACA).

Traditionally, the State of the Union address is where the President praises his Administration for the accomplishments of the past year and offers up new challenges and goals.  This year, in terms of healthcare, we got the praises for a job well done in implementing the ACA, despite the naysayers and helping to get the Ebola crisis under control.  Yet, the speech seemed to fall short on what will be the next goals facing the healthcare industry.

While we learned this week, the President saved new healthcare goals for an unprecedented announcement by Health and Human Services (HHS) Secretary Sylvia M. Burwell.  In a meeting with nearly two dozen leaders representing consumers, insurers, providers and business leaders, HHS set measurable goals and a timeline to move the Medicare program, and the healthcare system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.

HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.  HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.  This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.

To make these goals scalable beyond Medicare, Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network.  Through the Learning and Action Network, HHS will work with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models into their programs.  HHS will intensify its work with states and private payers to support adoption of alternative payments models through their own aligned work, sometimes even exceeding the goals set for Medicare.  The Network will hold its first meeting in March 2015, and more details will be announced by HHS in the near future.

The ACA created a number of new payment models with the goal of rewarding quality.  These models include ACOs, primary care medical homes and new models of bundling payments for episodes of care.  In these alternative payment models, healthcare providers are accountable for the quality and cost of the care they deliver to patients.  Providers have a financial incentive to coordinate care for their patients—who are therefore less likely to have duplicative or unnecessary x-rays, screenings and tests.

Secretary Burwell sees the HHS announcement as a means to continue the shift toward paying providers for what works.  By adopting a framework that categorizes healthcare payments according to how providers receive payment to provide care, HHS is directly linking payment to quality. The categories are:

  • Category 1—fee-for-service with no link of payment to quality
  • Category 2—fee-for-service with a link of payment to quality
  • Category 3—alternative payment models built on fee-for-service architecture
  • Category 4—population-based payment

Value-based purchasing includes payments made in categories 2 through 4.  Moving from category 1 to category 4 involves two shifts: (1) increasing accountability for both quality and total cost of care; and (2) a greater focus on population health management as opposed to payment for specific services.

Prior to 2011, many Medicare payments to providers were tied only to volume, rewarding providers based on how many tests they ran, how many patients they saw, or how many procedures they did, for example, regardless of whether these services helped (or harmed) the patient.  But under the ACA reforms by 2014, an estimated 20 percent of Medicare reimbursements had shifted to categories 3 and 4, directly linking provider reimbursement to the health and well-being of their patients.  The HHS goal announced this week is to transition fee-for-services with a link to quality from 20 percent to 50 percent of Medicare reimbursement by 2018.

Without a doubt, this announcement sets in motion a few more years of turmoil for healthcare clinicians and administrators.  For now, the only sure thing is there is much more that we need to learn about how Medicare plans to make this happen in less than a 24 month window.  Only time will tell whether a future State of the Union addressee will applaud this effort or denounce it.

To read a fact sheet about the goals and Learning and Action Network: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

This post was written and syndicated by MiraMed, A Global Services Company. Click here to learn more about MiraMed.

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ICD-10 QuestionsThis the most insightful and informative article I’ve read so far about the ICD-10 transition. It answers the who, what, and why questions to give the reader a holistic view of the seemingly elusive conversion to ICD-10. We can only wait and see what will happen this year. It’s well worth reading. Phil C. Solomon

Ten Questions about ICD-10

Even though, there has been a substantial amount of information published regarding the implementation of ICD-10 over the last ten years, there are many misconceptions that continue to plague the physician community. Rumors run rampant; some are valid while others are completely unfounded. Frequently we hear the need for change in healthcare, yet resistance to change continues to stifle our ability to move forward. The unknown is a scary place. It is more comfortable to work with an established system that is flawed rather than implement a new, technologically advanced system. Reflecting back several years ago with the implementation of the 5010 HIPAA electronic transactions standard, many organizations were negatively affected because they were not prepared, yet after some adjustments, 5010 is successfully operating behind the scenes with little to no effort. Let’s review ten questions concerning ICD-10 in an attempt to dispel the myths.

Who developed ICD-10?

The World Health Organization (WHO) developed the ICD-10 Clinical Modification (CM) diagnosis coding system. The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) develops and maintains the US version of ICD-10 CM. All modifications to ICD-10 are required to conform to WHO conventions. The physician community and healthcare industry had extensive input in the development of ICD-10 CM; in fact, much of the clinical detail was a result of the input received from physicians. So why all the resistance if the physicians gave much of the input?

What is the ICD-10 compliance date?

The looming question is “will there be another delay and if so when?” Currently, federal regulations require that ICD-10 codes be utilized for dates of service beginning October 1, 2015; thus, ICD-9 will expire on September 30, 2015. Once again, there has been much discussion regarding a delay of the implementation date. Last year’s delay was a political maneuver that was slipped in at the last minute to appease physicians because of the recurring Sustainable Growth Rate (SGR) issues. The delay surprised the Centers for Medicare and Medicaid Services (CMS), the American Academy of Professional Coders (AAPC), the American Health Information Management Association (AHIMA) and the entire healthcare community. Due to the multiple delays, it is understandable that the healthcare community has lost its confidence in the implementation taking place. As of the time this article is being written, it appears that legislation drafted by Representative Pete Sessions (R-TX) will include a two-year delay of ICD-10 for consideration by Congress.

According to CMS, it is estimated that the last delay cost the healthcare industry approximately $6.8 billion in lost investments, not including the cost associated with missed opportunities for better health data to improve quality of care and patient safety. A recent article in Modern Healthcare noted that “the proposal to delay implementation of ICD-10 diagnostic and procedure codes by an additional two years appears to be going nowhere in the current lame duck session of Congress.” It is recommended that we move forward until and unless we receive definitive information regarding a delay.

Why don’t we wait for ICD-11?

The projected date for the release of ICD-11 is 2017. The US version would then take another two years of revisions prior to release and implementation in 2019 at the earliest. In addition, ICD-11 builds on the concepts of ICD-10; therefore, it would be prudent to implement ICD-10 and become familiar with the new concepts and guidelines before upgrading to ICD-11. Greater diagnosis specificity is going to be necessary prior to 2019.

What is the impact on CPT codes?

The Current Procedural Terminology (CPT) codes will be unaffected by the implementation of ICD-10-CM.

How is ICD-10 implementation related to the Affordable Care Act (ACA)?

The implementation of ICD-10 is not part of the Patient Protection and ACA of 2009. ICD-10 is governed by HIPAA; therefore, it is not related.

Why should we change to ICD-10?

ICD-9-CM is obsolete and no longer able to reflect the many changes in healthcare, i.e., clinical knowledge and medical terminology advancements over the last 40 years. Today’s need for data is very different than it was 40 years ago. ICD-10 includes greater detail that will lead to better justification of medical necessity. Many interested parties anticipate that it will lead to fewer coding errors with fewer rejected claims because the system is more understandably structured and specified. It will be much easier to compare reported codes and check for consistency between diagnosis and procedure codes to identify illogical combinations of diagnoses and reduce opportunities for fraud. Hopefully there will be fewer gray areas.

What are the benefits of ICD-10 CM adoption?

Many physicians view the implementation of ICD-10 as onerous and expensive; there are many benefits that will offset this cost.

  • Improvements in patient outcomes and patient safety through better data for analysis and research
  • Improved ability to manage chronic diseases by better capturing patient populations
  • More accurate reflection of clinical complexity and severity illness in patients
  • Improved ability to identify high-risk patients who require more intensive resources
  • Improved ability to manage population health
  • Improved information sharing, which can enhance treatment accuracy and improve care coordination
  • Enhanced public health surveillance and improvement strategies
  • Improved ability to assess effectiveness and safety of new medical technology
  • Improved administrative efficiencies and lowered costs (e.g., fewer rejected and improper reimbursement claims, decreased demand for submission of medical record documentation) •• Justification of medical necessity
  • More accurate and fair reimbursement
  • More accurate representation of physician performance
  • Increased patient engagement (as a result of access to better data)
  • Validation for reported evaluation and management codes
  • Less misinterpretation by auditors, attorneys and other third parties

Can we just use the crosswalk from ICD-9 to ICD-10?

General Equivalence Maps (GEMs) to convert ICD-9 to ICD-10 should only be used as a guide for coding and not for the actual coding of claims. The code should be confirmed based on the clinical documentation presented. Many physicians find the volume of codes intimidating and the use of a crosswalk may seem to alleviate the stress of learning the whole new code set. Remember, 78 percent of the codes have a 1:1 relationship. This should dispel the fear about the number of ICD-10 CM codes. Laterality (right vs left) also accounts for almost 50 percent of the increase. The remaining 22 percent of codes will have a “one to many” relationship. These are the codes for which the crosswalk may not be applicable because they will need more clinical documentation in order to identify the appropriate ICD-10 CM code.

What about using external cause codes, signs/symptoms and unspecified codes?

As in ICD-9, the reporting of external cause codes has no mandatory requirement for reporting in ICD-10. It is only applicable under certain circumstances. Signs and symptoms, as well as unspecified codes, are also only reported under certain circumstances. It is important to report the code that represents the level of certainty known for that procedure or encounter. If the information is not known or available, then it is acceptable to report the appropriate unspecified code or the signs/symptoms. However, it is inappropriate to code unspecified or signs/symptoms if the information is available to the physician.

Where do we start ICD-10 training for our physicians?

According to AHIMA, the amount of training individual physicians will need is based upon the role they play within their practice. It is recommended that each practice perform an assessment to determine how their current documentation will compare to the documentation necessary to code ICD-10. Once this assessment is complete, the appropriate training for the organization can be determined. For instance, if a physician is doing their own coding, more extensive training will be required than for a physician who is documenting only and using the services of a coder. This assessment may alleviate the anxieties related to the implementation.

The key to a successful ICD-10 implementation is preparation. The time is now. Delaying practice assessment and training in hopes of a delay could potentially affect your cash flow for several months. It is better to be safe than sorry.

Author: Darlene Helmer, CMA, CPC, ACS-AN, CMPE, MBA
Vice President of Provider Education and Training, Anesthesia Business Consultants


References

http://www.AHIMA.org

http://bok.ahima.org/PdfView?oid=300625

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036866.hcsp?dDocName=bok1_036866%20

http://www.modernhealthcare.com/article/20141208/blog/312059996&utm_source=AltURL&utm_medium=email&utm_campaign=mpdaily

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ICD-10 LegislationThis year, payers and providers alike felt the effects from the decision to delay the ICD-10 transition until October 2015. Our representatives in Congress came up with the legislation that everyone could agree on (Lately, that hasn’t happened too often) to delay implementation of ICD-9 to ICD-10 until 2015…. and the President signed it. Now it seems “we are fixin” to have a good ole shootout at the O.K. Corral again between physicians and hospital executives. Instead of shooting it out themselves, they have placed Congress squarely in their sights and are beginning the lobbying process, even before we all kiss 2014 good-bye.

I’ve highlighted pieces of correspondence from representatives of AHIMA and The Texas Medical Association (I’m sure other State Hospital Associations are doing the same) sent to their constituents today. They both are making pleas to support their position to either postpone the implementation of ICD-10 again or have October 1, 2015 be the final drop dead date to transition to the new code set. Below are excerpts from their marketing letters:

AHIMA notice: ACTION NEEDED—OPPOSE EFFORTS TO DELAY ICD-10 TO 2017. “Recently, physician groups have asked Congress to delay ICD-10 until 2017. The 113th Congress will be considering health legislation for two more weeks before recessing for the year on Friday, December 12. Please contact your US Senators and Representatives today. Ask them to support the October 1, 2015 compliance date and vote “no” on any additional delays.

We cannot afford another delay. The Centers for Medicare and Medicaid Services estimated that the last delay has already cost the healthcare industry approximately $6.8 billion in lost investments, not including the cost associated with missed opportunities for better health data to improve the quality of care and patient safety. AHIMA’s Advocacy Assistant provides advocacy tools you can use contact your legislators. You can also learn more about what physician groups are asking Congress at the Journal of AHIMA website.”

TEXAS MEDICAL ASSOCIATION notice: “Join physicians from across the United States to ask Congress for a two-year delay in ICD-10. Ask Congress to delay the mandatory implementation until October 2017 so you and your colleagues can spend more time on patient care. Your patients deserve it.

It’s imperative that you contact your representative today and explain how you cannot afford the cost and disruption of ICD-10 implementation to your business, especially now, when you are buried in myriad other bureaucratic burdens. Take action now. It’s easy and doesn’t require much time. Just cut and paste the letter below onto your personal stationery, then send it to your representative by mail or by fax. It’s important the letter is on your personal stationery. Feel free to add your own personal reasons why ICD-10 is not a good idea. Explain how implementing ICD-10 now will affect your practice and will take even more of your time away from patient care. You can find the name, mailing address, and fax number of your U.S. representative in TMA’s Legislative Action Center.”

I expected this debate would heat up after the first of the year. I’m surprised to see the battle lines being drawn so early. I guess the earlier the better…..just like the way retailers are now promoting Christmas shopping way before Thanksgiving. In the words of the many Home Depot ads, I’ve seen lately, both groups are promoting a “Let’s Do This” attitude.

The words of a peaceful fighter, Mahatma Gandhi rings true: “First they ignore you, then they ridicule you, then they fight you, and then you win.” Who will come out the winner this time? Only time will tell!

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and is the Vice President of Global Services for MiraMed, a worldwide healthcare BPO company. MiraMed provides solutions to leading hospitals, health systems, large physician groups and industry partners providing services in the areas of revenue cycle optimization, medical coding, clinical authorization and technology integrations. Phil has 25 years of experience as an industry thought leader, strategist, solution provider, author and featured speaker at many industry educational conferences. His role as a trusted advisor to healthcare providers has given him the honor of working with some of the industry’s best and brightest leaders in healthcare finance and revenue cycle operations. 

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CMS Releases Final Rules on Medicare Physician Payments

In the Spring of thisSteth year, Congress voted to delay the ICD-10 implementation until October 2015. That decision has had a severe ripple effect, costing providers millions of dollars from wasted planning and preparation, technology purchases, coder training and many other costly expense items. This debacle turned out to be a major train wreck for hospital and physician practices as they scrambled to get ready for the transition. One of the sticking points and a key reason for the delay of ICD-10 was the adjustments to the Sustainable Growth Rate (SGR) for Medicare payments. This fee component dictates how much physicians get paid for services. The information below outlines the new CMS payment policy. – PCS

Last Friday the Centers for Medicare & Medicaid Services (CMS) released final rules that implemented changes and updates to payments made under the Medicare Physician Fee Schedule (PFS). Last year the Protecting Access to Medicare Act of 2014 prevented significant reductions to physician payment through the sustainable growth rate (SGR) formula, but this policy is in effect only until March 31, 2015. The new Congress will need to address physician payment early next year to prevent the significant reductions to payments that are scheduled to start in April 2015.

There are many policy changes to physician payment in the final rule; including this is the first year of implementation of the Value-Based Payment Modifier (VM), which increases or decreases physicians’ payments under fee-for-service Medicare based on the individual physician’s performance on quality and utilization measures. Many physicians face reductions in pay through the VM, Physician Quality Reporting system (PQRS) and electronic health records (EHR) Incentive Program—these could have a significant effect on profit margins for providers. CMS finalized the following changes:

CMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The content for this post was provided by MiraMed Global Services – a healthcare revenue cycle BPO company

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and is the Vice President of Global Services for MiraMed, a worldwide healthcare BPO company. MiraMed provides solutions to leading hospitals, health systems, large physician groups and industry partners providing services in the areas of revenue cycle optimization, medical coding, clinical authorization and technology integrations. Phil has 25 years of experience as an industry thought leader, strategist, solution provider, author and featured speaker at many industry educational conferences. His role as a trusted advisor to healthcare providers has given him the honor of working with some of the industry’s best and brightest leaders in healthcare finance and revenue cycle operations. 

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