HBMA 2016: THE HEALTHCARE REVENUE CYCLE CONFERENCE

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1 HBMA 2016: THE HEALTHCARE REVENUE CYCLE CONFERENCE In the Future of MIPs and APMs: Billing Companies are a Key to Data Deep Dives and Analytics Jennifer Searfoss, Esq., CPOM, CHCI, CMCS o e jen@scghealth.com Financial disclosure In accordance with the Accreditation Council for Continuing Medical Education s Standards for Commercial Support I publicly declare that: I don't have any direct financial control or relevant relationships over any of the healthcare products or services now or in the past 12 months. About Jennifer Jennifer Searfoss, Esq., CPOM, CHCI, CMCS is the CEO of the Searfoss Consulting Group, LLC since its founding in 2011 and is focused on value improvement, revenue cycle management and strategic planning in this post-health reform world. Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. Before going behind the iron curtain, Jennifer served as the External Relations Liaison for the Washington, DCbased Government Affairs Department of the Medical Group Management Association. 1

2 Learning objectives Summarize and understand the 2019 Medicare programs-mips and APMs Define data required for reporting analytics Identify and evaluate your infrastructure, technology and staffing needs Affordable Care Act 1:5 will close by 2020 predicts Emanuel wrote Ezekiel Emanuel, an architect of the Affordable Care Act in his book Reinventing American Health Care. 2

3 Making up for the industry s lack of ongoing investment Healthcare has unique security needs and is more like the banking industry. Overall costs decreased by move to secure cloud subscription services. The average year-over-year maintenance, upgrade and investment in IT is 2.5% of revenue for all sectors. That s $7,581 per user. Source: Computer Economics IT Spending & Staffing Benchmarks. Inspiring dramatic cultural change Involvement of patients and families Design principles A clear vision The cultural change required to succeed with team-based medicine is considerable. The organizational culture needs to embrace standardization and reliability and to act every day on the belief that the center of the care is the patient. Teamwork Cultural change Triple Aim focus Source: Rank, B. Triple Aim 2.0: Designing Culture and Care to Support Better Health, Better Experience at a Lower Cost. Group Practice Journal, February Institute for Healthcare Improvement Triple Aim Simultaneous pursuit of three aims Improving the experience of care Improving the health of populations Reducing per capita costs of healthcare 3

4 Now the technical stuff The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced the Medicare Sustainable Growth Rate with the Quality Payment Program with two budget neutral paths. Path 1: Merit-based Incentive Payment System (MIPS) PROPOSED 2016/ / / / /2022-4% MU -4% VBM 2% PQRS -4% MIPS -5% MIPS -7% MIPS -9% MIPS 4

5 Future with MIPS 15% SCORE Episodic 10% SCORE Attributed benes 25% SCORE 100 points Options for pts 50% SCORE points Quality Choose 6 measures Clinical Practice Improvement Cost Advancing Care Info Status Quo QRUR shows some data that may be helpful QRUR reports show attribution data 10 all or nothing objectives Non-participation = automatic -4% cut Choose 9 measures or a measure group or participate in an MSSP Non-participation = automatic -6% cut The last year of the incentive (2014) is the latest PQRS data we have available. Participation trends Penalty Source: Centers for Medicare & Medicaid Services Reporting Experience Including Trends ( ). PQRS program history (base year) % % % % % % % : 6% penalty 198 measures 266 measures 258 measures 284 measures 281 measures 284 measures 14 measure groups 22 measure groups 22 measure groups 25 measure groups 22 measure groups 25 measure groups Report 3 Measures Report 3 measures Report 3 Measures 1 domain Report 3 Measures Report 9 measures 3 domains 5

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7 Claims-based reporting Codes are entered just like charges. Penny charge is for clearinghouses that can t process zero charges. Will be available for a limited number of QDCs. The EOB will show remark code N620 to show that it was received. The anatomy of QDCs Title Mode of reporting Description Frequency The denominator explains what s considered an eligible encounter. Age, service and/or diagnosis codes are defined. Does age really count when it s a Medicare claim? Centers for Medicare & Medicaid Services. Version /17/2015. CPT copyright of the American Medical Association. 7

8 The anatomy of QDCs The numerator explains what meeting the measure really means. For claims-based reporting, HCPCS codes or CPT II codes are identified. To satisfactorily report, you must have at least ONE qualified encounter with the performance met over the entire year. The remaining 50% may be instances where the performance is not met. Caution: Was the data captured?! Centers for Medicare & Medicaid Services. Version /17/2015. CPT copyright of the American Medical Association. The anatomy of QDCs Definitions clarify what performance really means Centers for Medicare & Medicaid Services. Version /17/2015. CPT copyright of the American Medical Association. The anatomy of QDCs Performance met Non-performance of measure Exclusions Performance Patient not eligible for BMI BMInormal G8420 BMI above normal w/ plan G8417 BMI below normal w/ plan G8418 Possible Roles: Identifying eligible encounters now (backfill) and historical trends Alternative data capture Patient options not eligible using for code plan info All payer data Data mining ICD codes for opportunities for patient care Gaps in data capture BMI not taken, Exclusion G8422 BMItaken, no plan Exclusion G8938 BMI not taken BMItaken, no plan G8421 G8419 Centers for Medicare & Medicaid Services. Version /17/2015. CPT copyright of the American Medical Association. 8

9 Measure Groups Proposed to be eliminated in MIPS. Only available for individuals. Not available for GPRO. Possible Roles: Identifying eligible encounters Availability of patients for inclusion (20 total; 11 Medicare) Treatment Episode 2# OP Facility 8# Part B and and Trigger in Trigger in any any position position Look Back: Closing Rule: Colonoscopy X X 30 days from trigger 90 days from trigger date of episode Code Code Description Anesthesia for lower intestinal end procedures, endoscope intro distal to duodenum Anesthesia for; anorectal procedure Transfusion, blood or blood components Excision of rectal tumor, transanalapproach; Possible not including Roles: muscularis propria Hemorrhoidectomy, internal, by rubber band ligation(s) Hemorrhoidectomy, internal and external, Data 2 or more reports columns/groups; matching historical MRI, pelvis; without contrast material(s), followed data to by episodes contrast material(s) CT, abdomen and pelvis; with contrast material(s) New global periods MRI, abdomen; without contrast material(s), Quarterly check-ups on where C1749 Endoscope, retrograde imaging/illumination colonoscope device (implantable) J1756 Injection, iron sucrose, 1 mg the physician/group maps J2353 Injection, octreotide, depot form for intramuscular Care coordination injection, 1 mg information J2469 Injection, palonosetron hcl, 25 mcg transfer P fecal impaction constipation, unspecified slow transit constipation outlet dysfunction constipation other constipation Red blood cells, leukocytes reduced, each unit Solution for interoperability? Care coordination Possible Roles: Identifying patients for care coordination by diagnosis Longitudinal patient view Data transfer between clients? 9

10 QRUR drill down reports Practices will live in these reports. For procedure-related costs, they allow you to see where expenditures Possible Roles: are made and by whom for each patient. Data matching and reports Historical trending with past reports large groups KNOWING WHERE IT IS AND HOW TO GET IT! Where are they? Download your Quality and Resource Use Report (QRUR) from Only the Security Officer can access. CMS.gov > Medicare > Medicare FFS Physician Feedback Program/Value- Based Payment Modifier > How to Obtain a QRUR What s in the report and on the site The report itself: Table 1 Your attributed doctors. Important to double-check because PECOS is wrong. Table 2A MOST IMPORTANT FILE: patients attributed to your practice. Table 4 Patient cost attributed to your practice. Tables 5-10 Cost by Episode. 10

11 QRUR report: a road map These numbers will be different Super important to check this!!! QRUR report: a road map Approach recommendations Able to find enough?discussion on what QCDs are easiest to capture. What about specialties with less than six/nine measures, like anesthesia? Go Group. Consider GPRO to eliminate incident-to problems. Data capture. All about workflow. If there are problems, look at what s captured in the EMR. Then look at alternative measures. 11

12 Take home opportunities Historical data dives Identifying data gaps Knowledge support Data collection, collation and trends 12