October 20, 2015

Hot Topics Impacting PaymentsWV HFMA Fall Revenue Cycle Education

Jill Griffith, CPA, CPCSenior Manager - Health Care Services

Presented by:

What’s Hot

ICD -10 RAC updates Notice act Comprehensive Care for Joint Replacement (CCJR) Provider based department (clinic) update Two Midnight Rule – update Settlements – Phase II OIG Work Plan Proposed Medicare Physician Fee Schedule – FY 16 MIPS

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ICD 10 Go-Live

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Nightmare or Non-Event?

ICD 10Title

MLN Matter # SE 1325 Revised 8/4/2014 Split claims

Only impacts 10/1/2015 Applied to all bill types Require providers split the claim so all ICD-9 codes

remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2015 and later.

Issues for discussion

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ICD 10 – Potential Issues

Incorrect code mapping EHR system still mapping to ICD 9 codes

Quick identification and correction is key

Daily report fluctuations (such as daily revenue) Denial codes

Expand rejection codes

Unspecified codes – grace period? Denials?

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ICD 10 – Potential Issues

Productivity tracking Canada’s infamous 67% decline

Dual coding

Coder/physician pairing

Issues for discussion

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ICD 10 – What’s Next?

Revenue Cycle Continue training

Consider new hires

Diligence

Tracking

CAC

Back to basics

Keep Calm and….

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RAC Updates

Connolly Region C Approved issue 9/2/15 Complex Comprehensive Review

Documentation will be reviewed to determine if Cardiac PET scans meets Medicare coverage criteria, meet applicable coding guidelines and/or are medically reasonable and necessary.

CMS NCD Section 220.6.1 4/3/09; CMS NCD Section 220.6.8 1/28/05, CMS IOM 100-04 Chapter 13 Section 60.4

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Notice Act -

“Notice of Observation Treatment and Implication for Care Eligibility Act” Enacted 8/6/15 PL 114-42 Copy at:

http://thomas.loc.gov/cgi-bin/toGPObsspubliclaws/http://gpo.gov/fdsys/pkg/PLAW-114publ42/pdf/PLAW-114publ42.pdf

Effective 8/6/16 Applicable to all hospitals

Including IRFs, IPFs and LTACs Includes CAHs

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Notice Act

New Paragraph Y Beginning 12 months after the date of the

enactment – in the case of a hospital or critical access hospital, with respect to each individual who receives observation services as an outpatient at such hospital or critical access hospital for more than 24 hours, to provide to such individual not later than 36 hours after the time such individual begins receiving such services (or, if sooner, upon release)

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Notice Act

“(i) such oral explanation of the written notification described in clause (ii) and such documentation of the provision of such explanation, as the Secretary determines to be appropriate;

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Notice Act

“(ii) a written notification (as specified by the Secretary pursuant to rulemaking and containing such language as the Secretary prescribes consistent with this paragraph) which – (I) explains the status of the individual as an outpatient

receiving observation services and not as an inpatient of the hospital or critical access hospital and the reasons for such status of such individual;

(II) explains the implications of such status on services furnished by the hospital or critical access hospital (including services furnished on an inpatient basis), such as implications for cost-sharing requirements under this title and for subsequent eligibility for coverage under this title for services furnished by a skilled nursing facility.

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Notice Act

(III) includes such additional information as the Secretary determines appropriate;

(IV) either— (aa) is signed by such individual or a person acting on such

individual’s behalf to acknowledge receipt of such notification; or (bb) if such individual or person refuses to provide the signature

described in item (aa), is signed by the staff member of the hospital or critical access hospital who presented the written notification and includes the name and title of such staff member, a certification that the notification was presented, and the date and time the notification was presented; and

(V) is written and formatted using plain language and is made available in appropriate languages as determined by the Secretary.”

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Knee & Hip - CCJR

Published July 14th Federal Register Copy at

http://www.gpo.gov/fdsys/pkg/FR-2015-07-14/pdf/2015-17190.pdf

Proper name – Comprehensive Care for Joint Replacement 90 day post acute bundling proposal Not voluntary Mandatory in 75 MSAs

No WV MSA’s included.

Effective 1/1/16 5 year demo

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Knee & Hip - CCJR

Would hold only the participant hospitals financially responsible for the episode of care

Would apply to MS-DRG 469 (Major joint replacement or

attachment of lower extremity with Major Complication or Comorbidities (MCC)), or

MS-DRG 470 (Major joint replacement or reattachment of lower extremity without MCC)

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Knee & Hip - CCJR

Includes hospitals not participating in Model 1 or Phase II of Models 2 or 4 of the Bundled payment for care Improvement (BPCI) model for the lower extremity joint replacement clinical episode

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Knee & Hip - CCJR

Services Included Physician services Inpatient hospital services (including readmissions) IPF LTCH IRF SNF HHA Hospital outpatient services Independent outpatient therapy services Clinical lab DME Part B Drugs Hospice

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Knee & Hip - CCJR

Services excluded Acute clinical conditions not arising from existing

episode-related chronic clinical conditions or complications of the Lower Extremity Joint Replacement (LEJR) surgery

Chronic conditions that are generally not affected by the LEJR procedure or post-surgical care

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Knee & Hip - CCJR

Retrospective, two-sided risk model with hospitals bearing financial responsibility

Providers and suppliers continue to be paid via Medicare FFS After a performance year, actual episode spending would be

compared to the episode target prices. If in aggregate target prices are greater than actual episode spending, hospital may receive reconciliation payment

If in aggregate target prices are less than actual episode of spending, hospitals would be responsible for making a payment to Medicare

Responsibility for repaying Medicare begins in Year 2, with no downside responsibility in Year 1

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Knee & Hip - CCJR

MSA’s close by Ohio

Akron Cincinnati Toledo

Pennsylvania Harrisburg/Carlyle Pittsburgh Reading

Virginia Staunton/Waynesboro

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Knee & Hip - CCJR

Requesting postponement to July 2016 or January 2017

Question – reclassified hospitals in/out of MSA Expecting final rule – check for MSA changes

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Provider Based Department Update

Place of service changes Released 8/6/2015 Changes effective 1/1/2016

22 – On Campus-Outpatient Hospital -- A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

19 -- Off Campus-Outpatient Hospital -- A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

No changes to POS 11 – Office -- Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

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Two Midnight Rule Update

CMS sought to balance multiple goals, including: respecting the judgment of physicians; supporting high quality care for Medicare beneficiaries; providing clear guidelines for hospitals and doctors; and incentivizing efficient care to protect the Medicare trust funds.

In the CY 2016 OPPS proposed rule, CMS is: Proposing to change the standard by which inpatient admissions

generally qualify for Part A payment based on feedback from hospitals and physician to reiterate and emphasize the role of physician judgment

Announcing a change in the enforcement of the standard so that Quality Improvement Organizations (QIOs) will oversee the majority of patient status audits, with the Recovery Audit program focusing on only those hospitals with consistently high denial rates .

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Two Midnight Rule Update

Stays where physician expects < 2 midnights Payable on a case by case basis based on admitting

physician judgement MR documentation must support IP admission is medically

necessary Subject to medical review

Rare and unusual for minor procedures to be IP status Monitor and prioritize for medical review

Stays > 2 midnights – no change

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OMHA - Settlement – Phase II

Announcement 10/15 – Settlement Conference Facilitation (SCF) Pilot

OMHA resolved over 2400 unassigned ALJ appeals

Phase II – extensive list of eligibility requirements ALJ hearing request filed by 9/30/15 Claim = < $100,000 If extrapolated, <$100,000 Only Pt B claims

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OMHA - Settlement – Phase II

Submit SCF expression of interest form Prompts OMHA to run report of pending appeals, initiates process Report is CMS to decide if it will participate

Does not appear to be a timeframe for CMS’ response If CMS agrees, OMHA completes an SCF spreadsheet

Contains all eligible OMHA appeals Preliminary notification to appellate 15 calendar days to submit request for SCF package

Submitted via flash drive or cd Request for SCF form SCF Agreement of Participation form Completed SCF Request Spreadsheet

Appellate must ensure claims meet SCF eligibility requirements OMHA will work with appellate to resolve any issues as far as objections to the claims

on the SCF spreadsheet If appellate does not respond in 15 days case returns to its place in queue for ALJ

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OMHA - Settlement – Phase II

If agreement is reached OMHA drafts settlement agreement for signature Both CMS and appellate must sign Claims are still considered “denied” New RAs will not be issued

Supplemental insurance implications

OMHA also announced Phase III for next year will include some Part A appeals

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OIG Work Plan

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has the responsibility of detecting and preventing fraud, waste, and abuse in HHS programs as well as identifying opportunities to improve program economy, efficiency and effectiveness.

The OIG Work Plan summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.

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OIG Work Plan – FY 2016

Mid-year Update For 2015 and beyond continued focus on

Emerging payment Eligibility IT system security vulnerabilities in HC reform programs

Health insurance marketplaces

Efficiency and effectiveness of payment policies and practices

Areas mentioned Intensity-modulated radiation therapy (IMRT) Hospital preparedness and response to high-risk infectious disease Access to DME in competitive bidding areas Clinical lab payments IRF PPS requirements Use of HER to support care coordination through ACOs

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Proposed FY 16 - Medicare Physician Fee Schedule

“Incident to” Policy for Calendar Year 2016 In the calendar year 2014 PFS final rule, CMS required that, as a condition

for Medicare Part B payment, all “incident to” services and supplies must be furnished in accordance with applicable state law.  The definition of auxiliary personnel was also clarified to require that the individual furnishing “incident to” services must meet any applicable requirements to provide such services, including licensure, imposed by the state in which the services are furnished.

For 2016, CMS is proposing to clarify that the billing physician or practitioner for “incident to” services must also be the supervising physician or practitioner.  Additionally, CMS is proposing to require that auxiliary personnel providing “incident to” services and supplies cannot have been excluded from Medicare, Medicaid, or other Federal health care programs by the Office of Inspector General, or have had their enrollment revoked for any reason at the time that they provide such services or supplies.

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Proposed FY 16 - Medicare Physician Fee Schedule

First PFS proposed rule since the repeal of the Sustainable Growth Rate (SGR) formula by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Through the proposed rule, CMS is beginning implementation of the new payment system for physicians and other practitioners, the Merit-Based Incentive Payment System (MIPS), required by the legislation. 

The calendar year 2016 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.

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Proposed FY 16 - Medicare Physician Fee Schedule

Physician Payments Under the Value Modifier Program, performance on quality

and cost measures can translate into payment incentives for EPs who provide high quality, efficient care, while EPs who underperform may be subject to a downward adjustment.

This program is set to expire in CY 2018, as a new comprehensive program, required by MACRA, called the Merit-Based Incentive Program (MIPS) begins in CY 2019. Federal Register notice 10/1/2015 Comments due by 11/2/2015

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Proposed FY 16 - Medicare Physician Fee Schedule

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015)

Establishes a new methodology that ties annual PFS payment adjustments to value through a Merit-Based Incentive Payment System (MIPS) for MIPS eligible professionals (MIPS EPs)

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MIPS

MIPS annually measures Medicare Part B providers in four performance categories to derive a "MIPS score" (0 to 100), which can significantly change a provider's Medicare reimbursement in each payment year Value Based Modifier-measured quality (up to 30 points) Value Based Modifier-measured resource use (30

points) Meaning Use (25 points) new category named "clinical practice improvement" (15

points)

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QUESTIONS?

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Jill Griffith, CPA, CPC

Senior Manager - Health Care Services

voice: 800.642.3601

e-mail: jill.griffith@actcpas.com