Institute on Medicare and Medicaid Payment Issues. Baltimore Marriott Waterfront Hotel

Transcription

1 Institute on Medicare and Medicaid Payment Issues Baltimore Marriott Waterfront Hotel March 28-30,

2 Diagnostic Imaging Accreditation and Regulatory Requirements Today s Talk Attack on Payment MPPR Supervision issues Accreditation nexus with supervision CMS regulatory policies / developments 2

3 Multiple Procedure Payment Reduction First (most expensive) procedure is paid at 100 percent of the Physician Fee Schedule amount. Payment for second and subsequent procedures is reduced by 50 percent. Prior to CY 2012, MPPR policy applied to: The technical component (TC) of certain diagnostic imaging procedures furnished to a beneficiary in the same session MRI and MRA, CT and CTA, and ultrasound CY 2012 Expansion of MPPR The MPFS final rule adopted the proposal to apply the MPPR to the PC of the second and subsequent advanced imaging services furnished in the same session. Full payment is made for the PC of the highest paid procedure. Payment is reduced by 25 percent to the PC of the second and subsequent advanced imaging services, furnished by the same physician, in the same session, on the same day. 3

4 Future In MPFS proposed Expansion rule CMS seeks of comments MPPR on how it might expand the MPPR policy We will be aggressively looking for efficiencies in other sets of codes... and will consider implementing more expansive reduction policies in CY 2013 and beyond. The following are under consideration: Apply the MPPR to the TC of all imaging services (would include x-ray, EKG, EEG, etc.). Apply the MPPR to the PC of all imaging services (would include x-ray, EKG, EEG, etc.). Apply the MPPR to the TC of all diagnostic tests (would include cardiology, pathology). Supervision of Diagnostic Tests Medicare Supervision Rules Physician Offices IDTFs Provider-Based Entities HOPPS Hospital 4

5 Supervision of Diagnostic Tests Do not apply to hospital inpatients Teaching physician regulations Supervision and interpretation of interventional procedures Supervision of Diagnostic Tests Levels of Supervision General Supervision Direct Supervision Personal Supervision 5

6 Level One General Supervision The supervising physician does not need to be present for the test, but he/she has overall responsibility for the control and direction of the service. Level Two Direct Supervision The supervising physician need not be in the room when the procedure is performed, but must be present in the same office suite and immediately available to assist if required. 6

7 Level Three Personal Supervision The supervising physician must be in the same room where the test is performed throughout the procedure. Supervision in an IDTF Supervising physician must be proficient in the performance and interpretation of the tests they supervise. False Claims Act case against MedQuest Associates in federal court in Tennessee. 7

8 Hobbs v. MedQuest: Statement of Issues on Appeal Did the District Court err in ruling on summary judgment that MedQuest knowingly submitted false or fraudulent claims when it billed Medicare for diagnostic tests with contrast that were medically necessary and properly performed, but that were not directly supervised by a boardcertified radiologist or carrier-approved physician? Did the District Court err in ruling on summary judgment that MedQuest knowingly submitted false or fraudulent claims when it billed Medicare for diagnostic tests performed at a facility that was an enrolled Medicare provider, but that the government asserts was improperly classified as a physician's practice rather than an "independent diagnostic testing facility"? Are the civil penalties imposed by the district court grossly disproportional to the gravity of the offense, in violation of the Excessive Fines Clause of the Eighth Amendment? False Claims Act (31 USC ) As amended by the Fraud Enforcement and Recovery Act of 2009 (FERA), liability under the False Claims Act occurs when a person or entity: 1) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; 2) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; or 8

9 False Claims Act (31 USC ) (cont d) 3) conspires to commit a violation of any of certain provisions of the False Claims Act (including the two listed above). o Violations are punished by penalties of not less than $5,500 and not more than $11,000 per claim, plus treble damages for the amount of damages the Government sustains o Whistleblower (qui tam) suits are allowed o Reverse false claims provision now may reach selfdiscovered overpayments FCA actions can be based on Anti-kickback Statute and/or Stark Law violation. Why would one choose to enroll as an IDTF? 9

10 Supervision of Diagnostic Tests Non-Physicians Nurse Practitioners, Clinical Nurse Specialists and Physician Assistants are not physicians and may not function as supervising physicians under Medicare's Diagnostic Test Benefit. They may perform diagnostic tests pursuant to State Scope of Practice laws. 10

11 Supervision of Diagnostic Tests Performance of Diagnostic Tests by NPP NPP performs test (technical component only) requiring direct supervision NPP acting under his/her own benefit bill under NPP name and PIN Technical component reimbursed at 100% of MPFS Radiologist Assistants Radiology Practitioner Assistants Cannot supervise test for Medicare patient Cannot perform an invasive or surgical procedure for Medicare patients that are then billed under the NPI of a radiologist 11

12 HR 3032 Medicare Access to Radiology Care Act of 2011 Creates independent right to bill for RA services Payment to radiology group Does not permit RA to supervise a test HOPPS Supervision Rule Physician Supervision of Medicare Hospital Outpatient Diagnostic Tests 12

13 HOPPS Direct Physician Supervision Standard varies based on location: In the hospital or an on-campus providerbased department Off-campus provider-based department Under arrangement services HOPPS Direct Physician Supervision 2010 Rule In the hospital or an on-campus provider-based department "Direct supervision" means physician present on the same campus immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require presence in the room "Immediately available" no specific spatial or temporal standard 13

14 HOPPS Direct Physician Supervision 2011 Rule In the hospital or an on-campus provider-based department "Direct supervision" means immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require physical proximity "Immediately available" no specific spatial or temporal standard HOPPS Direct Physician Supervision 2010 Rule Off-campus provider-based department "Direct supervision" means physician present in the off-campus provider-based department of the hospital immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require presence in the room Note: multi-site-of-service building problem 14

15 HOPPS Direct Physician Supervision 2011 Rule Off-campus provider-based department "Direct supervision" means immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require physician proximity HOPPS Direct Physician Supervision Non-hospital location, i.e. mobile or fixed-site diagnostic testing facility furnishing services "under arrangements" "Direct supervision" means physician present in the office suite immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require presence in the room 15

16 HOPPS Direct Physician Supervision Qualifications: Does the supervising physician for imaging services have to be a radiologist? Physician must be qualified to furnish "assistance and direction" HOPPS Rule: "knowledgeable" about the test Transmittal 128, May 28, 2010 Transmittal 137, December 30, 2010 Accreditation Its Nexus with Supervision 16

17 MIPPA The Medicare Improvements for Patients and Providers Act of Accreditation Required for Advanced Diagnostic Imaging Services: o MR o CT o Nuclear Medicine (including PET) By 2012 Mandates Qualifications of Non-Physician Personnel Qualifications of Medical Directors and Supervising Physicians 17

18 General Supervision The physician s overall direction and control, but the physician s presence is not required during the performance of the procedure. Supervision and the Anti-Markup Rule The physician who performs (supervises?) the TC must share the practice 75% of all services assigned to billing group; or on-site where ordering MD regularly furnishes services 18

19 Anti-Markup Rule Who is the performing physician for the TC of a diagnostic test? Place of Service Billing 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 99 Other 19

20 Place of Service / Date of Service Instructions (Transmittal 1823, CR 6375, October 2, 2009) Chapter 26, et seq. Initially to be effective in Guidelines were delayed. CMS Transmittal 2407 February 3, 2012 Medicare Claims Processing Manual revised and clarified Place of Service (POS) coding instructions. 20

21 2012 Transmittal 2407 Place of Interpretation The place where technical component service was provided. POS for TC in Box 24-B. Zip Code for interpreting physician in Box 32. Does not cure carrier jurisdiction problem. Restrictions on Global Billing Global only if the same physician performed both the TC and the PC. See CMS Transmittal 1892 January 15, 2010 (Anti-Markup Rule) See CMS Transmittal 2407 February 3, 2012 (POS Instructions) 21

22 Also Restricting Global Billing Claims Process Manual, Chapter 1, (B) Claim submitted under new 5010 electronic standard location of health care services Paper claims require use of Zip codes of POS Date of Service No global billing for advanced imaging if DOS for TC and PC differ. 22

23 Anti-Markup Rule TC and PC Transmittal 1892 (CR 6733) (January, 2010) Mostly straightforward implements Antimarkup Rule But eliminates purchased interpretations and Zip Code billing by IDTFs Medicare Claims Processing Manual, Chapter Payment to Physicians or Other Suppliers of Diagnostic Tests Anti-Markup Rule Purchased tests and purchased interpretations eliminated Anti-markup tests no reassignment Can bill using Zip Code of interpreting physician, regardless of state, when billing an anti-markup test (Transmittal 1892) 23

24 Medicare Claims Processing Manual, Chapter Payment Jurisdiction for Reassigned Services The billing entity must submit claims to the B/MAC that has jurisdiction over the geographic area where the services were rendered. Suppliers and providers must also meet current enrollment criteria stated in Chapter 10 of the Program Integrity Manual in order to be able to bill for reassigned services. (Transmittal 1987) Thomas W. Greeson Reed Smith LLP 3110 Fairview Park Drive, #1400 Falls Church, Virginia Direct Fax tgreeson@reedsmith.com Donald H. Romano Foley & Lardner LLP 3000 K Street NW, Suite 600 Washington, DC Office (202) Fax (202) DRomano@foley.com 24