How to Prepare for Medicare Reimbursement. Kelly McCracken, Public Health Consultant September 26, 2017 North Carolina Lifestyle Coach Summit

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1 How to Prepare for Medicare Reimbursement Kelly McCracken, Public Health Consultant September 26, 2017 North Carolina Lifestyle Coach Summit

2 Objectives Develop an understanding of the key components and timeline for the most recent Medicare Diabetes Prevention Program (MDPP) proposed rule released in July 2017 Gain clarity on the steps organizations can take to prepare to be an MDPP Supplier

3 Background and Timeline Affordable Care Act (ACA) Section 1115A(c) Center for Medicare and Medicaid Innovation (CMMI) Healthcare Innovation Award (HCIA) to the Y-USA March 2016 Secretary of Health and Human Services announcement and Office of the Actuary certification July 2016 MDPP proposed rule (first round) November 2016 CY 2017 Physician Fee Schedule MDPP Final Rule (first round) July 2017 MDPP proposed rule (second round) November 2017 CY 2018 Physician Fee Schedule MDPP Final rule (second round) January 1, 2018 MDPP Supplier enrollment begins April 1, 2018 MDPP Supplier reimbursement begins

4 CY 2017 Physician Fee Schedule (first round) What was (partly) finalized: Expansion authority and timing MDPP beneficiary eligibility criteria Structure of the MDPP services MDPP supplier eligibility, enrollment, and compliance policies

5 CY 2017 Physician Fee Schedule (first round) What was left out: Payment structure Program integrity policies Virtual

6 Current Proposed MDPP Policies in the CY 2018 Physician Fee Schedule: Expansion authority and timing MDPP beneficiary eligibility criteria Structure of the MDPP services Payment structure MDPP supplier eligibility, enrollment, and compliance policies Virtual

7 Support from CMS There will be a CMS service center for MDPP suppliers

8 Expansion Authority and Timing MDPP services will be available January April 1, 2018 Supplier enrollment will begin January 1, 2018 MDPP services are additional preventive services They are NOT subject to Medicare Part B coinsurance or deductible A beneficiary has no liability for covered MDPP services An MDPP supplier cannot bill or collect from the beneficiary any amount

9 MDPP Beneficiary Eligibility Criteria: Enrolled in Medicare Part B BMI of at least 25 or at least 23 if self-identified as Asian Have, within the 12 months prior to attending the first core session: HgbA1c test with a value between 5.7 and 6.4 or Fasting plasma glucose of mg/dl or 2-hour post-glucose challenge of mg/dl No previous diagnosis of type 1 or type 2 with the exception of gestational diabetes (GDM) Do not have end-stage renal disease (ESRD) No previous receipt of MDPP services

10 Referral Policy: Self-referral Community-referral Health care practitioner-referral (which includes non-physician practitioner referrals)

11 Structure of MDPP Services Core Services Period Ongoing Services Period Core Sessions Months 1-6 Core Maintenance Sessions Months 7-12 Ongoing Maintenance Sessions Up to 24 months 16 weeks 1 class per week 1 class per month 3 month intervals 1 class per month 3 month intervals MDPP Services Period

12 Structure of MDPP Services Make-up sessions Same curriculum topic Maximum of one per week No limit Virtual make-up sessions Maximum of 4 during the core services period Maximum of 3 that are ongoing maintenance sessions during a 12 month time period

13 Structure of MDPP Services Beneficiaries who meet the eligibility criteria would only be able to receive MDPP services once in their lifetime. This includes the ongoing services period. Beneficiaries can change MDPP suppliers

14 Payment Structure Performance Goal WITH minimum wt loss 1 st core session $25 4 total core sessions $30 9 total core sessions $50 3 sessions attended in first core maintenance session interval (months 7 9) 3 sessions attended in second core maintenance session interval (months 10 12) WITHOUT minimum wt loss $60 $10 $60 $10 5% wt loss $160 $0 9% wt loss (anytime during the MDPP services period) $25 $0 3 sessions attended in ongoing maintenance session interval $50 $0 TOTAL $810 $125

15 Payment Structure Weight measurements used for determining beneficiary eligibility for coverage or supplier payment must be taken in-person Bridge payments $25 for first session attended with new MDPP supplier To submit a claim, the new MDPP supplier must have documentation in the beneficiary s MDPP record (from previous supplier) No limit to the beneficiary

16 Payment Structure Submitting claims Must have documentation in the beneficiary s MDPP record Only submit when a performance goal is met Must report the NPI of the coach who furnished the session Reporting HCPCS G-Codes on claims 19 unique Healthcare Common Procedure Coding System (HCPCS) G-codes Relate to the performance payments

17 Performance Goal WITH min. wt loss WITHOUT min. wt loss 1 st core session $25 HCPCS G-code GXXX1 4 total core sessions $30 HCPCS G-code GXXX2 9 total core sessions $50 HCPCS G-code GXXX3 3 sessions attended in first core maintenance session interval (months 7 9) 3 sessions attended in second core maintenance session interval (months 10 12) $60 GXXX6 $60 GXXX7 5% wt loss $160 GXXX8 9% wt loss (anytime during the MDPP services period) $25 GXXX9 3 sessions attended in ongoing maintenance session interval Bridge payment $50 GXXX10-17 $25 GXXX18 $10 GXXX4 $10 GXXX5 $0 $0 $0

18 Who Can Enroll as an MDPP Supplier? MDPP suppliers are at the organizational level Existing Medicare suppliers have to enroll separately as MDPP suppliers Interim preliminary recognition under CMS authority Met 12 months of reporting on at least one completed cohort (with at least 5 participants) 60% attended at least 9 sessions in months % attended at least 3 sessions in months 7-12 Full recognition from the CDC s Diabetes Prevention Recognition Program (DPRP)

19 MDPP Supplier Enrollment Application Coach information NPIs First, middle, and last names SSN DOB Business information Administrative location(s) must have at least one Reporting timely updates to CMS

20 What are the Enrollment Policies for an MDPP Supplier? High Categorical Risk screening regulations in (c) Enrollment regulations in 42 CFR part 424, subpart P Time limits for filing claims Requirements to report and return overpayments Procedures for suspending, offsetting or recouping Medicare payments in certain situations Obtain an National Provider Identifier (NPI)

21 What is High Categorical Risk Screening for Suppliers? Screening regulations in (c) Site visit by CMS Fingerprints required from anyone who has 5% or more ownership interest in the organization Background checks Revalidation Moderate Risk every 3 years

22 MDPP Supplier Standards Billing privileges terminated for State Medicaid program Ineligible coaches Legitimate, operational organizations Cannot be a private residence Signage posted on the exterior of the building Legal business name Hours of operation Be open for business with staff or volunteers present during operational hours Have a phone number available to the public

23 MDPP Supplier Standards Beneficiary access Capacity limit must publicly available Must maintain a record of anyone turned away Offer and provide the entire set of MDPP services Disclosure Coverage for the set of MDPP services One-per-lifetime limit Eligibility requirements MDPP supplier standards

24 MDPP Supplier Standards Beneficiary complaints Must answer, respond to, and document Must keep a record for 10 years Evaluation Compliance Crosswalk file includes anyone with one claim Submit performance data for ongoing maintenance sessions

25 MDPP Suppliers Documentation Requirements Maintain detailed records of services provided within a medical record Initial core session Organizational name, CDC DPRP organization number, and organizational NPI Basic beneficiary information Evidence of eligibility Each additional session Type of session Curriculum used Coach NPI Date and place of service Weight

26 MDPP Suppliers Documentation Requirements Retain participant medical records for ten years and provide access to CMS upon request Handle protected participant data in compliance with HIPAA and other standards

27 Beneficiary Engagement Incentives In-kind sole responsibility of the MDPP supplier Reasonably connected to the CDC-approved curriculum Preventive care item or service or advances a clinical goal Can t be a reward for achieving an outcome Can t be advertised or promoted by the MDPP supplier Technology - $100 retrieved and $1000 not to exceed Must be documented if over $25

28 What Can Your Organization Be Doing Now? Read the current proposed MDPP rule (pages ) Understand High Categorical Risk screening Understand the application process to enroll in Medicare - PECOS Download free software to submit claims PC-ACE Pro32 Review process for obtaining an NPI Continue to work toward obtaining full-recognition from the CDC s DPRP Work with provider groups to encourage Medicare beneficiary referrals with blood-based values

29 For more information: Visit the CMS website and sign up to receive updates : -diabetes-prevention-program/ Visit the AADE DPP Network to look for workshops, trainings and webinars that review and prepare your program for successful and sustainable DPP implementation

30 Questions? Thank you

The CDC National Diabetes Prevention Program

The CDC National Diabetes Prevention Program Program Overview of the Diabetes Prevention Recognition Program (DPRP) Elizabeth Ely, MS Division of Diabetes Translation Overview of the National DPP and DPRP