Non-Physician i Providers

Transcription

1 Non-Physician i Providers Colleen M. Schmitt, MD, MHS, FACG, FASGE Galen Medical Group Chattanooga, TN cschmitt7@comcast.net 1

2 To define the steps to develop ancillary infusion and histopathology services To recognize the regulatory challenges to ancillary service provision To understand how NPP can add value to outpatient and inpatient GI services To describe how integrating NPP into practice can impact delivery of care Infusion Pathology Anesthesia Weight loss clinic Laboratory* Imaging * Research * Drug dispensing* We have deep depth. --Lawrence Peter Berra * Especially if Multi-specialty group 2

3 Practice integration Coordinated clinical pathways Improved communication between specialists Control of data, quality, costs bundle Decreased costs and increased convenience for patient in a familiar and comfortable setting Patient adherence Opportunity for patient interaction and education Standard of care at point of service 3

4 Equipment Quantity Cost Infusion chair 2 $3,000 Infusion pump 2 $3,400 BP monitor 1 $1,500 Update office space $2,500 Entertainment $1,500 Misc. supplies $1,500 --IV catheters, tubing, extension sets --IV poles --locked refrigerator --stocked crash cart --medications Total start up costs $13,400 Staff Check state licensure Salary, benefits limitations for medication RN, NP, PA infusion Rent Other support staff 4

5 BUY AND BILL Establish account with wholesaler for specialty Rx Purchase Rx from vendor Bill patient s insurance plan ASSIGNMENT Covered under Rx drug plan Requires preauthorization Specialty pharmacy ships specific doses for patient Specialty pharmacy verifies insurance information and bills copayment Examine individual prescription drug policies and procedures Research various vendors to verify most competitive prices Guarantee availability CPT Descriptor Examples Payment Hydration 1 st hour NS $ Hydration additional hour NS $ st hour infusion Anti-TNF $ Each addition hour infusion Anti-TNF $ IV push, single drug Prednisone $57.50 Diphenhydramine H2 Blocker Additional sequential IV push of new drug Above $ Chemo admin, SQ or IM Methotrexate $

6 Single denial = thousands of dollars Manage with infrastructure Preauthorization Pay staff by service rather than hourly Ensure no practice tax on drug Only one initial code in the drug administration family; all other codes must use a subsequent code All supplies are included and cannot be billed separately local anesthesia; IV start; access to indwelling IV, SQ catheter/port, flushes; standard tubing, syringes Bill for drug wastage as per contract (-JW modifier) Bill E/M service if patient has separate, identifiable problem that requires this (-25 modifier is suggested) Includes nursing visit 6

7 Start-up costs 570 s.f. lab $110,000 Histology technician $23.35/hr Lab manager, Director $36,000/yr Rent $41,700/yr Supplies $25,560/yr 52% reduction in 2013 Medicare Fee Schedule for Level IV path CPT Technical Component (TC) Increase in Professional Component (PC) by 2% Overall 33% decrease in Global 7

8 Local group versus outside Hiring issues Part of team Desirable lifestyle Per unit payment Assume ~ 60 specimens per day or more CPT Descriptor PC TC Global Level IV Path $36.74 $33.34 $ H. Pylori $26.54 $71.11 $ Iron $11.91 $55.80 $ Immunohistochemistry $42.19 $73.15 $

9 Proposed TC cut of 7% Proposed limit to practice expense payments used to calculate the technical component (TC) of pathology services to the lesser of the amount paid at either the hospital outpatient amount or ambulatory surgery center payment rate PC cut 1-2% Volume-based billing In-Office ancillary services exception (Stark) H.R. 2914, the Promoting Integrity in Medicare Act of 2013 Offset by Appropriate Use Criteria Anti-markup payment limitation Oversight requirements License and certification; accreditation Liability Further payment cuts Decision support tools 9

10 iopsies per Case Average # Bi Our biopsy behavior did not change before and f bli h d l b b i f i after we established lab or by site of service P=NS Physician Office '12 Office '13 HOPD '12 HOPD '13 10

11 Increase revenue Wasted time Delegatable time Improve lifestyle Productive time Enhance patient care Provide transitional services Help address physician shortage issues Augment educational support Reduce use of ED/observation units Patient access Throughput = Revenue More throughput costs money... Extended hours Monday, Monday! Increased number work-in slots Preventive visits Follow-up of chronic conditions More efficient use of specialist time in procedures and complex cases 11

12 Reduced no-shows Appointments at patient s best time rather than mine Decreased time interval between initial contact and appointment Reduced barriers 28% of consumers would be likely to use a retail clinic if they could be seen immediately rather than wait up to a week to see a doctor in a doctor s office 2009 Survey of Health Care Consumers: Key Findings, Strategic Implications Deloitte Center for Health Solutions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Scheduling Tests Follow-up results Fixed Costs Utilization by Hour 12

13 Strong staff affiliations, high visibility Provide improved continuity of care, achieve the strong quality metrics, and ensure high levels of patient satisfaction delivering evidence-based care Allows 15-20% complex patients to see MD Risk stratification by triage, scheduling, NPP Nurse Practitioners Physician Assistants Degree(s) awarded d Master s Degree or Doctor Physician i Assistant t of Nursing Practice (DNP) Certified (PA-C), usually also a Master s Degree # practicing in U.S. 155,000 83,600 % in specialty care 20-30% 20% # educational programs 257 (DNP) 170 Base salary (average) $91,310 $94,870 Scope of Practice AANP National NP Compensation Survey 2011 AAPA Census Report 13

14 CMS 2014 PFS Final Rule: Must...meet any applicable requirements to provide the services, including licensure, imposed by the State in which the services are being furnished. 1. Diagnose and treat acute, minor, or chronic conditions 2. Provide E/M services 3. Order tests 4. Assist during surgery 5. May have prescriptive authority Productivity over 50% that of MD In office productivity 150% that of GI MD Anticipated work RVU*: Mean 3,124 in office setting (range, 2,460-3,966) Mean 3,030 in facility setting (range, 1,958-4,328) Facilitate scheduling of lab tests, endoscopic procedures, breath tests, etc. * Combined data, two practices,

15 Description of Procedure, Test EGD 428 Colonoscopy 586 Hp breath test 109 Celiac serologies 126 FIT/FOBT 339 Iron stores 203 Stool studies for diarrhea evaluation ,041 N Analysis FTE NPP, Aug 2012-Jul 2013 Direct Costs Indirect Costs Salary, benefits, payroll taxes, liability Marketing coverage Medical Assistant salary, benefits Space, utilities, business insurance, professional fees Supplies Time for physician supervision and chart review 15

16 Incident To Direct Bill Physician i NPI NPP own NPI Independently credentialed 100% PFS 85% PFS services furnished as an integral although incidental part of a physician s personal professional service Medicare Benefit Policy Manual (Chapter 15, Section 60)...OR... Blend Often out of office (hospital, procedures) Urgent visits may be new problem May vary by payer Understand your role in engagement and review I review 100% in order to stay current with patient problems Open, continuous access to me for case review You cannot bill Medicare for incident to in a hospital setting either outpatient, inpatient, or in the emergency department 16

17 Medicare policy defines a shared visit as a medically necessary encounter with a patient where the physician and a qualified MLP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. The rules for billing such shared/split visits depend on the setting and the type of services rendered. In the hospital setting the shared visit may be reported under the physician NPI as long as the physician provides any face-to-face portion of the E/M encounter with the patient. If the physician does not see the patient faceto-face then report service under NPP NPI. 17

18 44.8% NPP have hospital privileges Cost less than MD FTE Manage care of patients not requiring direct MD time Facilitate and coordinate care processes Prescriptions, appointments, communication, d/c planning and summaries Enhance efficiency Augment practice productivity 2012 AANP Sample Survey Hospital inpatient Hospital outpatient Hospital observation Hospital discharge Emergency department Office and non-facility clinic visits Prolonged visits associated with any of the above E/M services Remember the 3 Sames and a Some rule: Same employer Same patient Same day Some face-to-face time with the patient 18

19 Consultation services Critical Care services Services provided in a nursing facility Procedures CONSIDER... Medical liability 2% named as primary defendant in 2011 Decreased face time Potential redundancy Competition Hospital employment by NPP may create new challenges TIPS FOR SUCCESS... Define role Provide patient with a choice Clear and open communication with your NPP (professional and supervisory support) Clear communication with patients about credentials (badge, signage) 19

20 This is all about practice integration and improving care Own your costs and control quality Allow office and clinical staff to work to highest level of license and competence Provide access, availability 20