Hot Topics Impacting Payment to Hospitals OHA Annual Meeting

Transcription

1 Hot Topics Impacting Payment to Hospitals OHA Annual Meeting Presented by: Jill Griffith, CPA, CPC Senior Manager - Health Care Services June 13, 2016

2 Agenda 2 New Modifiers & Place of Service (POS) Codes Bipartisan Budget Act Proposed OPPS Rule Two Midnight Rule Notice Act RHC Mania Increasing False Claims Penalties Merit-Based Incentive Payment System & Alternative Payment Models Comprehensive Care for Joint Replacement

3 New Modifiers & POS Codes 3 CMS seeks a better understanding of the conversions of physician practice to providerbased departments Added modifier PO (CMS Form 1450/UB-04) Off-campus provider-based outpatient departments Voluntary until 1/1/16 Changed/added POS descriptions for professional claims Changed POS 22 description provider-based on-campus outpatient department Added POS 19 provider-based off-campus outpatient department CMS reminder only Medicare Commercial payors and Medicaid may be 1500 with POS 11

4 New Modifiers & POS Codes 4 Hospitals should be billing with these codes now Remember this applies to outpatient departments paid under PPS Make sure any new locations converted follow the new requirements Pay attention to new Bipartisan Budget Act

5 Bipartisan Budget Act On November 2, 2015, President Obama signed into law the Bipartisan Budget Act of Effective January 1, 2017, Section 603 of the Budget Act excludes from Medicare s outpatient prospective payment system (OPPS) new hospital services furnished at an off-campus hospital outpatient department. The Act effectively adopts site-neutral payment principles recommended by MedPAC and more recently the GAO, whose December 2015 report concludes that given the trend toward hospital-physician consolidation, Congress should equalize payment rates for similar services provided in different settings to ensure Medicare is not paying too much for health care.

6 2017 Proposed OPPS Rule 6 Should align regulation with the BBA and answer such questions as: How non-grandfathered sites will bill for services Billing and payment for services only covered under OPPS Impact (if any) on the 340B Drug Discount Program and whether new off-campus locations may be considered child sites Whether grandfathered sites can move or add new services Treatment for off-campus locations that were under construction Treatment for a grandfathered off-campus location that is later determined not to meet provider-based regulations at 42 CFR Section

7 Two-Midnight Rule OPPs Rule April 18, 2016 Permanently removes Two-Midnight Rule Repay FY 15 and 16 with 2017 increase of 0.6% Replacing Two-Midnight Rule with a written notice under the Notice Act

8 8 Notice Act Proposed Rules Medicare Payment Traditional Physician Office Notice of Observation Treatment and Implication for Care Eligibility (Notice) Act Enacted August 6, 2015 Requirement for hospitals and CAHs Notice to Medicare observation patients > 24 hours Required no later than 36 hours of observation status Before discharge, transfer or admitted

9 9 Notice Act Proposed Rules Medicare Payment Traditional Physician Office 2017 IP PPS Proposed Rule Revising Medicare conditions of participation Requires CMS to develop the Medicare Outpatient Observation Notice MOON Similar notice requirement exists at State level for NY, CT, MD, PA and VA MOON must be: Presented to (in writing) Verbally discussed with Signed by Medicare observation status patients Impacts PPS Hospitals and CAHs Effective by August 6, 2016

10 10 Notice Act Proposed Rules Medicare Payment Traditional Physician Office MOON Requirements Explain outpatients in observation status vs IP The reason for the observation status Explanation of implications Explanation of cost-sharing requirements Post-hospitalization eligibility for Medicare SNF coverage Include a blank additional information section May be signed by a person acting on behalf, or If refused, by a staff member Include name and title and reason for signature refusal Includes Medicare Advantage or other Medicare health plan Regardless of whether there is Medicare Part B coverage Does not imply appeal rights English version to Office of Management and Budget for approval Will be subject to public review and comment CMS listening session December 21,

11 Rural Health Clinics (RHC) 11 Increase in number of conversions of physician offices to RHC designation Why now? Provider-based = reimbursable on Medicare cost report = 340b Drug Discount Program Provider-based < 50 beds and/or CAH = Medicare cost reimbursed with no cap Provider-based > 50 beds = Medicare cost reimbursed Subject to cap which is $81.32 for 2016

12 Rural Health Clinics 12 Rural Health Clinics: BBA Section 603 does not apply If CAH, 35 (15) driving miles from a hospital or CAH does not apply Provider-based RHC qualifies as a child site for the 340b Drug Discount Program Cost reimbursed RHCs: < 50 beds and/or CAH, meets provider-based rules Include on cost report Not subject to cap > 50 beds, meets provider-based rules Include on cost report Subject to cost cap Free-standing RHCs not on cost report Subject to cost cap

13 Rural Health Clinics 13 Rural Health Clinics: Is location rural? Areas considered urban clusters still qualify for rural for RHC rule find census date by entering a street Is the location in Health Professional Shortage Area (HPSA), or Is the area in a Medical Underserved Area (MUA)? Must have been certified as HPSA or MUA in preceding four years MUP does not qualify If HRSA states MUA/MUP call State primary care office to be sure MUA

14 Rural Health Clinics 14 Staffing must have a mid-level working at least 50% of RHC open hours Services: Services and supplies commonly furnished in a physician s office (i.e., history, exam, assessment of health status, treatment for a variety of medical conditions) Lab tests: Chemical examinations of urine Hemoglobin or hematocrit Blood glucose Occult blood Pregnancy Primary culturing for transmittal to a certified lab RHC must have available drugs & biologicals commonly used in life-saving procedures RHC must be able to represent that at least 51% of the clinic s total operating schedule be devoted to primary care Does not preclude RHCs from offering specialty services Productivity standards: Physicians = 4,200 annually Mid-levels = 2,100 annually

15 RHC Cost Cap Comparative 15 Medicare cost cap $81.32 CPT Code MPFS POS

16 RHC Billing Change 16 Effective 4/1/16, RHC s HCPCS code required for each line of service (MLN Matter MM9269, CR 9269) RHC visit line item with rev code 052x Prof component of qualifying health service & approved preventive services 0900 Qualifying mental health services 0780 Telehealth originating site facility fees Total charges for the encounter less any charge for approved preventive service Payment and coinsurance is based on this line item HCPCS and charges for all other RHC services furnished is reported Example: 052X /1/ /1/

17 RHC Is It Right for You? 17 Are you planning a new provider-based location off-campus? Do you meet location requirements? Can you meet staffing? Is productivity an issue? Do you dispense drugs at the location or are there a number of non-generic prescriptions written? If the answer to the majority of questions above is yes, perform a financial feasibility to determine if RHC is the right choice for your hospital.

18 Increased FCA Penalties on the Horizon 18 May 2, 2016, US Railroad Retirement Board Interim Final Rule Implemented penalties of $10,781 to $21,563 per claim Effective August 1, 2016 Impacts RRB claims including Medicare Railroad claims False Claims Act $5,000 to 10,000 per claim Debt Collection Improvement Act 1996 increased $5,500 to $11,000 per claim Act requires adjustments for inflation Expectation was calculations based on % to maximum of $15,000 RRB calculated corrections based on 1986 penalty amounts resulted in 216% increase FCA expected to increase before August 1, 2016 Take-aways: Ensure compliance programs have all effectiveness elements in place Proactive auditing and monitoring Self-reporting

19 Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APM) 19 Medicare Access and Children s Health Insurance Program (MACRA) Repealed Sustainable Growth Rate Formula for calculating physician payments Implemented two performance-based paths Continue under MPFS Bonus or penalty based on eligible provider s MIPS performance or Earn separate incentive payments through participation in an Alternate Payment Model and be excluded from MIPS participation

20 Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APM) 20 Proposed Rule April 27, 2016 Transition to Merit-Based Incentive Payment System and Alternate Payment Models Sunsets existing payments adjustments Physician Quality Reporting System Physician Value-Based Payment Modifier Meaningful Use Program for eligible providers Comments through June 27, 2016

21 Merit-Based Incentive Payment System 21 MIPS-eligible clinicians: Physicians Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse Anesthetists 4 performance categories: Quality Resource use Clinical practice improvement activities Meaningful use of EHR technology Eligible clinicians performance is negative or positive adjustment to payment First performance period is January to December 2017 for payments adjusted in calendar year 2019

22 Alternative Payment Models 22 Two types: Advanced APM or Other Payer Advanced APMs 3 Requirements (virtually the same): Use certified EHR technology Provide payment based on quality measures comparable to MIPs and Be either a Medical Home Model or bear more than nominal risk for monetary loss

23 Comprehensive Care for Joint Replacement 23 Bundled Payments Rural vs Urban Emergent vs Elective CJR Final Rule November 16, $400,000 procedures, > 7 billion hospitalizations Variation - $16,500 to $33, participants in 67 MSAs (CMMI April 2016) Hospitals not in BPCI models 1, 2 or 4 Hospitalization & 90 day post-discharge episode triggered by eligible Medicare fee for service in DRG 469 or 470 Five year program April 1, 2016 December 31, 2020

24 Comprehensive Care for Joint Replacement 24 Hospitals hold financial risk for achieving a target price and quality metrics for a joint replacement episode Incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers Estimated savings to Medicare of $343 Million

25 Comprehensive Care for Joint Replacement 25 OH MSAs: Akron Cincinnati OH-KY-IN Toledo IN MSAs: Southbend-Mishawaka Indianapolis-Carmel-Anderson PA MSAs: Reading Pittsburgh Harrisburg-Carlisle WV & KY: None

26 Comprehensive Care for Joint Replacement 26 Episode target price for hips and knees DRG 469 DRG 470 Paid normally throughout the year End of year comparison Actual spending for the episode (total expenditures for related services under Medicare Parts A and B) is compared to the Medicare target episode price) set by end of 2016 for the responsible hospital Adjusted for the participant hospital s quality and post episode spending performance: The hospital may receive an additional payment from Medicare or Be required to repay Medicare for a portion of the episode spending

27 Comprehensive Care for Joint Replacement 27 What s next? Congestive Heart Failure Acute Myocardial Infarction Chronic Obstructive Pulmonary Disease Oncology services

28 QUESTIONS? Jill Griffith, CPA, CPC Senior Manager - Health Care Services voice: x jill.griffith@actcpas.com