RECOVERY AUDIT CONTRACTORS RAC SUBSCRIPTION SERVICE Being Proactive Telemedicine Rule and CMS Updates May 10, 2011 2011 Aegis Compliance & Ethics Center, LLP 1
Faculty Brian Annulis, JD Partner, Meade & Roach, LLP 773.907.8343 bannulis@meaderoach.com Ryan Meade, JD Partner, Meade & Roach, LLP 773.472.3975 rmeade@meaderoach.com 2011 Aegis Compliance & Ethics Center, LLP 2
RAC Subscription Service: Webinar Overview RACs: Being Proactive Second Tuesday of each month Discuss one or two high-risk areas for RAC review Review ideas on how to proactively audit Propose operational safeguards RACs: What are We Learning Fourth Tuesday of each month Keep subscribers up-to-date on RAC developments Discuss RAC updates Analyze publicly available decisions involving RACs Pool questions from subscribers 2011 Aegis Compliance & Ethics Center, LLP 3
RAC Subscription Service: Webinar Overview Regularly scheduled Webinars will be supplemented, as necessary, with special emergency sessions Administrative Matters Each session will be 60-75 minutes in duration, including a question and answer session Each session will begin at 12:00 PM CT If you are unable to participate in the live discussion, each session will be recorded and made available in MP3 format 2011 Aegis Compliance & Ethics Center, LLP 4
Goals The goals of the RAC Webinars: Teaching/knowledge transfer Practical points Assist organizations to develop in-house methods of managing Please share your thoughts, suggestions (and criticisms) Our Perspective Defend your claims: Appeals process is critical Manage your compliance risks: Compliance implications to a RAC review must be addressed the RAC process is not just about RAC recovery Be proactive and preemptive 2011 Aegis Compliance & Ethics Center, LLP 5
Today s Topics and Agenda New Medicare Telemedicine Credentialing & Privileges Rule for Hospitals and CAH Catching up on CMS Transmittals (March & April) Waiver of co-insurance and deductible for certain preventive care services HOPPS updates New Medicare overpayment interest rate Change in screening HIV NCD 2011 Aegis Compliance & Ethics Center, LLP 6
COPs: Telemedicine Credentialing & Privileges On May 5, 2011, CMS published a final rule changing CoPs for hospitals, including critical access hospitals (CAHs) Implements a new credentialing and privileging process for physicians and practitioners providing telemedicine services Effective July 5, 2011 2011 Aegis Compliance & Ethics Center, LLP 7
COPs: Telemedicine Credentialing & Privileges Under current CoPs, the governing body of a hospital and CAH must appoint members of the medical staff after considering the recommendations of existing members of the medical staff Historically, hospitals accredited by the Joint Commission were deemed to have satisfied the Medicare CoPs Congress terminated statutory recognition of the Joint Commission s automatic deeming authority effective July 15, 2010 Now the Joint Commission must now obtain CMS approval of its standards in order to confer Medicare deemed status on hospitals 2011 Aegis Compliance & Ethics Center, LLP 8
COPs: Telemedicine Credentialing & Privileges Joint Commission had allowed accredited hospitals to privilege distant site physicians and practitioners Privileging by proxy standards Technically not in accordance with Medicare CoPs But... 2011 Aegis Compliance & Ethics Center, LLP 9
COPs: Telemedicine Credentialing & Privileges Concern raised by Joint Commission accredited hospitals about Medicare s interpretation of its CoPs in regard to privileging and credentialing of telemedicine physicians and practitioners CMS determined that its CoP requirements in regard to telemedicine privileging and credentialing was duplicative and burdensome On May 26, 2010, published a proposed rule to eliminate regulatory impediments and to allow for the advancement of telemedicine 2011 Aegis Compliance & Ethics Center, LLP 10
COPs: Telemedicine Credentialing & Privileges Final rule permits hospitals and CAHs that deliver telemedicine services to rely on the credentialing and privileging information from the hospital providing the telemedicine services (distant-site facility), provided certain conditions are met: Distant-site hospital providing telemedicine services is a Medicareparticipating hospital Individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services Individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving telemedicine services is located Recipient hospital provides distant-hospital with evidence of internal review for use in periodic appraisal of the distant-site physician or practitioner (at a minimum, this must include all adverse events and complaint) 2011 Aegis Compliance & Ethics Center, LLP 11
COPs: Telemedicine Credentialing & Privileges Previously, CMS required hospitals and CAHs to make individualized considerations of each remote practitioner's qualifications before granting privileges to such practitioners, even though the practitioners already had been credentialed and privileged by the distant-site facility 2011 Aegis Compliance & Ethics Center, LLP 12
COPs: Telemedicine Credentialing & Privileges The final rule also permits hospitals and CAHs to rely on credentialing and privileging information from non-medicare participating hospitals and other entities, such as physician practices or ambulatory surgery centers that provide telemedicine services, so long as there is a written agreement between the hospital or CAH and the telemedicine entity stating that the distant-site facility will provide services that permit the hospital or CAH to comply with all applicable CoPs, including the CoPs addressing credentialing and privileging 2011 Aegis Compliance & Ethics Center, LLP 13
COPs: Telemedicine Credentialing & Privileges CMS broadly defines such "distant-site telemedicine entities" as facilities that: (1) provide telemedicine services; (2) are not Medicare-participating hospitals; and (3) provide contracted services in a manner that permits a hospital or CAH using its services to meet all applicable CoPs 2011 Aegis Compliance & Ethics Center, LLP 14
COPs: Telemedicine Credentialing & Privileges Written agreement with distant-site telemedicine entity must satisfy the following provisions: Distant-site telemedicine entity s credentialing and privileging process and standards must satisfy standards at 482.12(a)(1)-(7) (Medical staff CoP) Individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity Individual distant-site physician or practitioner holds a license recognized by the State in which the hospital whose patients are receiving telemedicine services is located Recipient hospital provides distant-hospital with evidence of internal review for use in periodic appraisal of the distant-site physician or practitioner (at a minimum, this must include all adverse events and complaint) 2011 Aegis Compliance & Ethics Center, LLP 15
COPs: Telemedicine Credentialing & Privileges In response to public comments to the proposed rule, CMS recognized that without permitting these other entities to provide telemedicine services, it would not likely achieve its goals of increasing timely patient access to medical services and enabling smaller hospitals and CAHs to improve their access to specialty services by increasing their use of telemedicine services But, distant-site telemedicine entities are to be accountable to hospitals and CAHs for meeting the CMS practitioner credentialing and privileging standards 2011 Aegis Compliance & Ethics Center, LLP 16
COPs: Telemedicine Credentialing & Privileges Don t forget State law General rule is that a physician/practitioner is required to obtain a license to practice in every state in which the physician/practitioner reaches to treat or diagnose a patient through telemedicine Some states explicitly address telemedicine in their licensing laws Other states indirectly address telemedicine through reference of practice electronic mechanisms or by any means or instrumentality Some states require full licensure to provide telemedicine. Others require a special telemedicine license. Others require endorsement or registration 2011 Aegis Compliance & Ethics Center, LLP 17
Clarification on Preventive Care Coinsurance Waivers CMS issued Transmittal 864 on March 2, 2011 Titled: Waiver of Coinsurance and Deductible for Preventive Services. Clarifies waiver of co-insurance and deductible for certain preventive care services per the Affordable Care Act (ACA). Recall, Medicare Part B covers 80% of the cost of covered items and services. Patients pay 20% of the cost (co-insurance/copay). ACA waives co-insurance for certain services and does not apply service to deductible. 2011 Aegis Compliance & Ethics Center, LLP 18
Clarification on Preventive Care Coinsurance Waivers List of preventive care services covered by Medicare: initial preventive physical examination (IPPE) annual wellness visit Pneumococcal, influenza, and hepatitis B vaccine and administration; Screening mammography; Screening pap smear and screening pelvic exam; Prostate cancer screening tests; Colorectal cancer screening tests; Diabetes outpatient self-management training (DSMT); Bone mass measurement; Screening for glaucoma; Medical nutrition therapy (MNT) services; Cardiovascular screening blood tests; Diabetes screening tests; Ultrasound screening for abdominal aortic aneurysm (AAA); and Additional preventive services (identified for coverage through a national coverage determination (NCD), currently this is limited to HIV testing). 2011 Aegis Compliance & Ethics Center, LLP 19
Clarification on Preventive Care Coinsurance Waivers However, co-insurance and deductible not waived for all of these services. Certain covered preventive care services do not have the co-insurance waived because they do not have a high enough recommendation by the United States Preventive Services Task Force: digital rectal examination provided as a prostate screening service glaucoma screening DSMT services Barium enema as part of colorectal cancer screening (however, separate statute waived deductible) 2011 Aegis Compliance & Ethics Center, LLP 20
Clarification on Preventive Care Coinsurance Waivers Note on preventive care physical exams: they do not use 9- series CPT codes Initial Preventive Physical Examination: G0402-G0405 Annual Wellness Visit: G0438-G0439 And co-insurance waiver varies: G0402: waived G0403: not waived G0404: not waived G0405: not waived G0438: waived G0439: waived 2011 Aegis Compliance & Ethics Center, LLP 21
Hospital OPPS Updates CMS issued Transmittal 2174 on March 18, 2011 Titled: April 2011 Update of the Hospital Outpatient Prospective Payment System (OPPS) The document is part of a recurring update notification series that is undertaking to explain OPPS coverage and billing rules. The series do not create new rules, but clarifies existing rules. The most recent focuses on a variety of OPPS drug rules Note that likely that CMS would only be issuing these clarifications if they are noticing significant errors Consider putting issues onto compliance auditing and monitoring plan 2011 Aegis Compliance & Ethics Center, LLP 22
Hospital OPPS Updates Use of HCPCS Code C9399: As stated in Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, section 90.3, hospitals are to report HCPCS code C9399, Unclassified drug or biological, solely for new outpatient drugs or biologicals that are approved by the FDA on or after January 1, 2004 and that are furnished as part of covered outpatient department services for which a product-specific HCPCS code has not been assigned. It is not appropriate to report HCPCS code C9399 for drugs and biologicals that are defined as usually self-administered drugs by the patient as defined in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, section 50.2. 2011 Aegis Compliance & Ethics Center, LLP 23
Hospital OPPS Updates Reporting units: Hospitals and providers are reminded to ensure that units of drugs administered to patients are accurately reported in terms of the dosage specified in the full HCPCS code descriptor. That is, units should be reported in multiples of the units included in the HCPCS descriptor. For example, if the description for the drug code is 6 mg, and 6 mg of the drug was administered to the patient, the units billed should be 1. As another example, if the description for the drug code is 50 mg, but 200 mg of the drug was administered to the patient, the units billed should be 4. Providers and hospitals should not bill the units based on the way the drug is packaged, stored, or stocked. That is, if the HCPCS descriptor for the drug code specifies 1 mg and a 10 mg vial of the drug was administered to the patient, hospitals should bill 10 units, even though only 1 vial was administered. 2011 Aegis Compliance & Ethics Center, LLP 24
Hospital OPPS Updates Mixing of drugs: CMS reminds hospitals that under the OPPS, if two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each product used in the care of the patient. The mixing together of two or more products does not constitute a "new" drug as regulated by the Food and Drug Administration (FDA) under the New Drug Application (NDA) process. In these situations, hospitals are reminded that it is not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by the FDA on or after January 1, 2004, for which a HCPCS code has not been assigned. 2011 Aegis Compliance & Ethics Center, LLP 25
New Overpayment Interest Rate CMS issued Transmittal 187 on April 12, 2011 Titled: Notice of New Interest Rate for Medicare Overpayments and Underpayments-3rd Notification for FY 2011. CMS adjusts the overpayment interest rate quarterly The Medicare contractors shall implement an interest rate of 11.00% effective April 19, 2011 for Medicare overpayments and underpayments. 2011 Aegis Compliance & Ethics Center, LLP 26
An NCD Change: HIV Screening CMS issued a transmittal on April 22, 2011 which set out new coverage and billing rules for screening HIV tests Modification to NCD 190.14 (Diagnostic HIV Tests) Recall, Medicare is principally an acute and chronic care health insurance program. It covers very few screening services or preventive care services. Implementation date: July 6, 2010 (!) Statutory change allowed coverage since January 1, 2009, but various parts of the Medicare program work on their own time line! Parts of the rule have been in place since December 2009. 2011 Aegis Compliance & Ethics Center, LLP 27
An NCD Change: HIV Screening CMS relies on recommendations from the US Preventive Services Task Force (USPSTF) Coverage Rules: A maximum of once annually for beneficiaries at increased risk for HIV infection (11 full months must elapse following the month the previous test was performed in order for the subsequent test to be covered), and, A maximum of three times per term of pregnancy for pregnant Medicare beneficiaries beginning with the date of the first test when ordered by the woman s clinician. Note: Medical record documentation must evidence physician s reasoning for the patient being at risk 2011 Aegis Compliance & Ethics Center, LLP 28
Follow-Up Questions? questions@aegis-compliance.com audiocourses@aegis-compliance.com Next Lecture: Tuesday, May 24, 2011 12pm CT/1pm ET 2011 Aegis Compliance & Ethics Center, LLP 29