Medical Practice Issues to Watch in 2019

Originally published in the January 9, 2019 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Medical Practice Issues to Watch in 2019

2019 promises to be another busy year in healthcare. The 2018 midterm elections shifted the balance of power in Washington as Democrats now hold the gavel in the U.S. House of Representatives, creating a divided Congress with the Republican-held Senate. MGMA has identified the following legislative and regulatory issues critical for medical practices in the coming year. We will keep members apprised of key developments in these areas and their impact on medical practices and will continue to advocate for policies that enable practices to thrive in their mission to furnish high-quality, cost-effective patient care.

1. HHS doubles down on risk

Despite an anemic pipeline of new voluntary Medicare alternative payment models (APMs) trickling out of the Department of Health and Human Services (HHS), Secretary Alex Azar is planning a new approach to accelerate participation in risk-based APMs. Forgoing incremental implementation, the Secretary is expected to unveil new mandatory models in 2019 and to emphasize performance-based risk as a necessary component of any new APM.

MGMA strongly supports voluntary participation in APMs when it makes financial sense for individual practices and disagrees with the Secretary that the way to expedite the move to value-based care is to mandate participation. We will continue to advocate for new opportunities for practices to participate in voluntary APMs and for development of more physician-led models.

2. Regulatory relief from government burdens

It is expected that Congress and the Administration will continue to work toward reducing the regulatory burden on medical practices participating in government healthcare programs. The Centers for Medicare & Medicaid Services’ (CMS’) “Patients Over Paperwork” initiative is one such example. However, this has translated into only modest relief for practices thus far, as 88% of MGMA members polled reported an increase in overall regulatory burden last year. MGMA will continue to make regulatory relief a top advocacy priority in 2019. Keep up with our efforts at mgma.com/regrelief.

3. Kicking back the Stark Law

As part of the effort to accelerate payment innovation, HHS leaders pledge to revisit antiquated fraud and abuse rules such as the Stark Law and Anti-Kickback Statute. In 2019, watch for proposed rules that expand exceptions and safe harbors to protect value-based arrangements and benefit providers willing to take on performance-based risk.
While a push to simplify Medicare compliance rules is welcomed, it is likely that congressional intervention will be necessary to achieve meaningful reform. It remains to be seen if Congress will also prioritize this issue in 2019.

4. Surprise! Here is a medical bill you didn’t expect

Medical practices can expect to see a push to curb surprise medical bills, including efforts to empower patients and consumers through improved access to healthcare cost information. The sticker shock of surprise hospital bills continues to make headlines and draw bipartisan attention in Congress, making this issue ripe for legislative action in 2019.

5. A spoonful of new regulations to help drug prices go down

With a new Congress and support from the Administration, reducing Medicare drug prices is on the action list for 2019. For physician-administered drugs, one proposal seeks to curb the price of drugs in Part B by tying prices to a new International Price Index, create new private-sector vendors to supply practices with drugs, and set drug administration cost as a flat fee. CMS is also looking to give Part D drug plans greater flexibility to negotiate drug prices in protected classes.

6. The stakes are higher in MIPS

Implementation of the Merit-based Incentive Payment System (MIPS) continues to ramp up. In 2019, MIPS performance will determine whether clinicians receive a positive or negative payment adjustment of up to 7% on 2021 Medicare reimbursement. Medicare is accelerating cost accountability for MIPS clinicians by increasing the cost component to 15% of the overall MIPS score and introducing episode-based measures. The performance threshold required to avoid a payment penalty also doubles from 15 to 30 points in 2019. With more on the line this year, it is critical that MGMA members prepare their practices for success. Visit mgma.com/macra for helpful resources.

7. Data interoperability a priority for feds

The Office of the National Coordinator for Health Information Technology (ONC) is expected to release regulations to meet requirements of the 21st Century Cures Act and facilitate improved data sharing between healthcare entities. ONC will define and seek to discourage “information blocking,” develop a framework to facilitate data movement between heath information exchange entities, and release specifications for the use of apps to foster data exchange between different providers and between providers and patients. The goal of using apps, a component of MIPS and Stage 3 Meaningful Use, is to permit practices to efficiently and securely move administrative and clinical data via their EHR.

8. Cybersecurity continues to be a top practice concern

Medical practices can be a prime target for phishing and other cybersecurity attacks because they possess valuable information assets (patient clinical and financial data) and often have inadequate cybersecurity protections. HHS’ HIPAA enforcement arm is expected to ramp up audits and fines in 2019. Medical practices should protect both their data and business continuity by completing a comprehensive risk assessment, identifying vulnerable areas of the organization, and taking the steps necessary to mitigate risk. Check out MGMA security resources to prepare your practice this year.

9. Site-of-service payment differentials remain a target

Policymakers will continue the trend toward site-neutral payments with the goal of equalizing Medicare payments for the same services across clinical sites. Medicare expanded this policy through 2018 rulemaking by phasing-in payment reductions for clinic visits at hospital outpatient departments (HOPDs), including HOPDs excepted from previous site-neutral payment rules. In addition to saving money for patients and the government, site-neutral payments are viewed as a policy lever for increasing market competition, eliminating the incentive for hospitals to purchase freestanding clinics and leveling the playing field.

10. “Repeal and replace” is out, “Medicare for all” is in

This shift in power within Congress will recast the role the federal government plays in healthcare in 2019. With “Medicare for all” a key platform for many progressives during the 2018 primaries, the politicized debate over a single-payer health system shows no signs of slowing down and will likely gain steam ahead of 2020 elections.
Passage of any major health reform bill is highly unlikely anytime soon. However, as presidential contenders begin campaigning for the 2020 primaries, universal healthcare will almost certainly become a point of debate.

Clinical Decision Support Mechanisms (CDSM)

You know that can you’ve been kicking down the road?
Well, don’t look now but it’s starting to roll back!

by John Lillie, Senior Strategic Accounts Manager, CMS Imaging, Inc.

And it’s more like a 55-gallon drum that is slowly picking up speed.

Clinical Decision Support Mechanisms (CDSM) utilize Centers for Medicare and Medicaid Services (CMS) approved Appropriate Use Criteria (AUC). These CDSMs must be consulted prior to completing an order for either CT, MRI, Nuclear Medicine, or PET studies for Medicare outpatients in any non-inpatient place of service. CMS has targeted reporting for eight clinical areas to identify outlier physicians:

  • Coronary artery disease (suspected or diagnosed)
  • Suspect pulmonary embolism
  • Headache (traumatic or non-traumatic)
  • Hip Pain
  • Low Back Pain
  • Shoulder Pain (to include suspect rotator cuff injury)
  • Cancer of the Lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Ordering providers don’t have to abide by what was shown to be the best imaging modality; they must only demonstrate that they consulted AUC through an approved mechanism. Failure to consult an approved AUC will cause the professional and technical component reimbursement to be denied – as in zero-dollar reimbursement. That should get your attention.

The goal is admirable: reduce the number of inappropriate exams, which would improve the quality of healthcare by reducing dose where applicable. Good for the provider and good for the patient. However, as always, the devil was, and still is, in the details.

Originally slated to go in effect on January 1, 2016, this initiative has been delayed time and time again, and thankfully so. Neither CMS, nor the providers, nor the industry was prepared to implement these standards. Like peeling away the layers of an onion, the deeper reasonable interests investigated the topic, the more challenges became apparent. Available space to devote to the resultant coding is an issue, for example.

Moreover, what about those providers who still use the fax machine or paper orders? How are we going to get all providers, regardless of their specialty or size, to do this? These are real-world challenges.

A more significant challenge is that not everyone knows enough about the AUC consultation requirement, the approved mechanisms, and all of the other details, and are nowhere close to implementing a workable solution. Plus, there is no funding mechanism provided externally to help you to comply with the mandate. Assuming you have addressed this, I am quite sure that this was a pleasant conversation for radiology managers to have with their CFO’s (I sincerely hope you’ve had these conversations, right?). Apparently, many have not.

In a recent survey conducted by the Association for Medical Imaging Management (AHRA), among the 291 total responses who responded to the question “Have you implemented or begun implementing Clinical Decision Support (CDS)?”, 35% responded Yes, 61% responded No, and 3% were not sure what CDS is (Source: Regulatory Affairs: Clinical Decision Support (CDS) 05/2018 Survey, released on July 5,2018).

The good news is that since the passing of PAMA 2014, healthcare entities have far more choices available today as to which CDSM they would like to consider. The list of qualified Provider-led Entities (qPLE) who have been approved to “develop, modify, or endorse” Appropriate Use Criteria (AUC) are growing as well (see the list at the end of this blog posting). Newly approved qPLE’s are announced each June. The industry around Clinical Decision Support for Medical Imaging is growing. More choices allow for more informed decisions. More options will enable the marketplace to reward those who succeed and punish those whose products don’t pass muster.

What is a more significant concern, now that the mandate has been pushed back to January 1, 2020, is will the industry still be ready? The first year will, in effect, be an educational and operations testing period, but full compliance will be the standard for the second year. It is my concern that this reality has not become real. According to Sheila M. Sferrella, MAS, RT(R), CRA, FAHRA, Chair of the AHRA Regulatory Affairs Committee and President of Regents Health Resources, “It typically takes 12-18 months to implement a program like AUC in a hospital setting. Budgeting, funding, IT interfaces, RFP or vendor selection, and then implementation. This regulation is the most challenging one we have had to implement on the hospital side because we have to make sure we capture the AUC code from the referring physician so that the hospital gets paid and then somehow transfer that information to the radiologist’s professional group for payment. It includes hospital bling forms and physician billing forms where codes do not necessarily populate in the same place. The AHRA (The Association for Medical Imaging Management) is working with a group of industry leaders to find a solution that is electronic and not manual. We are trying to help our members prepare for implementation.”

The AHRA has been at the forefront of working with the CMS and their members to find a solution. I count myself as a member of this organization, and I applaud their actions on this front.

It is vitally important that the radiology industry examine, explore, and make their voices heard on the selection of the best CDSM for their facility. They should lead the charge on selection because it is their world that bears the responsibility for it to work. Moreover, they will be the ones penalized if they do not implement the change.

The can that was kicked is now rolling back. According to Ms. Sferrella, the likelihood that this initiative will be again kicked down the road is “almost none.” While some may have hoped this would happen, or the initiative will die and go away, that is not going to happen.

In summary, it is always a better outcome to plan and prepare before a crisis hits. Acting at the last minute, deciding and implementing a CDSM to make the deadline, usually results in panic buying and a whole lot of stress. There is still time, but it is running out faster than you think.  January 1, 2020, is now just 12 months away.

Approved qPLE’s as of this writing:

  • American College of Cardiology Foundation
  • American College of Radiology
  • Banner University Medical Group-Tucson University of Arizona
  • CDI Quality Institute
  • Cedars-Sinai Health System
  • Intermountain Healthcare
  • Massachusetts General Hospital, Department of Radiology
  • Medical Guidelines Institute
  • Memorial Sloan Kettering Cancer Center
  • National Comprehensive Cancer Network
  • Sage Evidence-based Medicine & Practice Institute
  • Society for Nuclear Medicine and Molecular Imaging
  • University of California Medical Campuses
  • University of Utah Health
  • University of Washington School of Medicine
  • Virginia Mason Medical Center
  • Weill Cornell Medicine Physicians Organization

2018 Alliance sponsor article provided courtesy of CMS Imaging, Inc.  For more information, please contact John Lillie of CMS Imaging, Inc. – jlillie@cmsimaging.com.

North Carolina’s Move to Medicaid Managed Care

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This interview is part of a new collaborative series made possible by Business of Healthcare (BOH) and the North Carolina Medical Group Management Association (NCMGMA). These interviews further our mission to provide high-level continuing education content for our members while highlighting key players and issues in North Carolina’s healthcare industry.

In this interview:

cohen300aMandy K. Cohen, MD, MPH
Secretary, Department of Health and Human Services
State of North Carolina

Mandy Cohen, MD, MPH, Secretary of the Department of Health and Human Services for North Carolina, spoke with Business of Healthcare about the state’s transition to Medicaid managed care as well as efforts to impact social determinants of health and curb opioid abuse. The interview was recorded live with 200 physician practice leaders at the North Carolina Medical Group Management Association Fall Conference. Dr. Cohen will also be one of our Advocacy Days speakers on March 13, 2019 in Raleigh, NC.

Follow this link to view the interview video

Continuing Education Credit

By reading, watching or listening to the full interview, you may self-report to earn 0.5 hours Continuing Education Credits for Certified Medical Practice Executive (CMPE) or Fellow of the American College of Medical Practice Executives (FACMPE) credentials.

NCMGMA and BOH thank Mako Medical Laboratories
for helping to make this interview series possible.
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About the Business of Healthcare

BOH was founded as a forum and information exchange for the 40,000 decision makers leading hospitals and health systems, physician practices, pharma, device, and senior living as well as government and commercial payers. These leaders, and innovators serving them, join Business of Healthcare interviews to solve the complex issues they face together.

Hosted by Matthew Hanis, each interview balances Margin & Mission: making good healthcare accessible to all. New subscribers come to BOH through your referrals. Please share our content with your colleagues and invite them to join our expert community.

Upcoming Interviews

Upcoming interviews in the series feature Jeff James, Chief Executive Officer of Wilmington Health; and Chad Price, Founder and Chief Executive Officer of Mako Medical Laboratories.

Interested in Participating?
If you are interested in being interviewed or have a tip on someone who would be a great interview candidate, please contact Melissa Klingberg in the NCMGMA offices at melissa@ncmgm.org.

NCDHHS Partnering with Appriss Health to Provide Controlled Substances Reporting System Integration

Appriss Health press release published November 26, 2018

The North Carolina Department of Health and Human Services (NCDHHS) will utilize Appriss Health‘s PMP Gateway integration service to provide NarxCare and North Carolina Controlled Substances Reporting System (CSRS) information to prescribers and pharmacists in the state directly within electronic health record and pharmacy management systems.

PMP Gateway is a managed service enabling the integration of the NarxCare platform and prescription drug monitoring program (PDMP) information into electronic health record (EHR) and pharmacy management systems, and other clinical information systems.

NarxCare utilizes, analyzes, and presents information from North Carolina’s CSRS to enable clinicians to better identify patients that may be at risk for substance use disorder, overdose, and death. NarxCare equips these clinicians and care teams with advanced analytics, tools, technology, and invaluable insights that are presented and accessed within clinical workflow. NarxCare provides machine learning and artificial intelligence-based patient risk scores and other information in a visually interactive format to aid prescribers and pharmacists with clinical decision support. NarxCare also helps clinicians connect patients with additional resources within their community if needed, such as medication-assisted treatment.

By delivering NarxCare and CSRS information within workflow through PMP Gateway, this one-click process eliminates the need for prescribers and pharmacists to manually log into the CSRS website separately and then enter a patient’s name and demographics to search for them. By providing easy, instant access to real-time information and insights, Appriss Health helps healthcare providers and pharmacists to better evaluate and quickly intervene on the behalf of patients.

“We are committed to doing everything possible to address North Carolina’s opioid epidemic,” said Mandy Cohen, M.D., Secretary of the N.C. Department of Health and Human Services. “I encourage prescribers and pharmacies to take advantage of these tools, which can save lives by identifying patients in need of treatment.”

By giving prescribers and pharmacists direct access to the state’s PDMP information and NarxCare, North Carolina is further enhancing its aggressive, multi-pronged approach to curbing the opioid epidemic in the state. NCDHHS’ data shows that almost 1,700 unintentional opioid-related deaths occurred in 2017. By enabling NarxCare in clinical workflow, North Carolina is demonstrating its dedication to creating a more useful and powerful technology infrastructure, delivering innovative insights that go beyond basic CSRS data, and defining a care strategy that is necessary when dealing with patients impacted by the opioid epidemic. NarxCare in workflow can help clinicians identify when a potential problem with a patient arises, and alerts clinicians to respond.

“We commend the state and public health officials in North Carolina for all that they have done this year to help confront and control the opioid epidemic,” said Rob Cohen, President of Appriss Health. “It is clear that access to information and insights will continue to be a powerful asset in the fight against drug addiction, and improving the careful management, care, and treatment for those who need it most.”

To learn more about the immediate availability of NarxCare and CSRS information in clinical workflow for all prescribers and pharmacists in North Carolina, visit, please visit https://www.ncdhhs.gov/divisions/mhddsas/ncdcu/csrs/integration.

Dems take the House in 2018 midterms: What’s next for healthcare

Originally published in the November 7, 2018 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Following last night’s elections, Democrats won the U.S. House of Representatives for the first time since 2010, while Republicans will likely increase their numbers and maintain control of the Senate. Healthcare issues dominated the campaign cycle, yet it remains to be seen what role healthcare will play in agenda-setting for the upcoming Congress. One issue now unlikely to advance on the legislative front is the repeal of the Affordable Care Act (ACA). Democrats have solidified their ability to block any ACA repeal bill, and Republican leaders appear open to supporting aspects of the ACA such as protections for pre-existing conditions.

The Democratic victory in the House means new leaders will chair key committees overseeing health policy. Nancy Pelosi (D-Calif.) is expected to reclaim her role as Speaker of the House and has promised to make drug pricing a priority for the next Congress. The Trump administration has similarly prioritized this issue, but it is unclear whether leaders from the administration and Senate will work together with House leadership on their shared priority to lower drug costs.

Billing Under Another Provider’s Number Can Land Physicians in Hot Water

By Emma Cecil, JD, October 31, 2017

2018 Alliance sponsor feature article courtesy of MagMutual

An Oklahoma physician agreed last August to pay the government $580,000 to resolve allegations that he violated the False Claims Act (“FCA”) by causing false claims to be submitted to Medicare for services he did not provide or supervise. According to the government, the physician allowed a company that employed him and in which he had an ownership interest to use his national provider identification (NPI) numbers to bill Medicare for physical therapy evaluation and management services furnished by other providers.

This case is merely another example of government enforcement action against providers who submit or cause to be submitted claims for services using the name and NPI of a physician who did not personally furnish the services. Back in 2011, the University of North Texas Health Science Center paid the government $859,500 to resolve allegations it had for submitted claims for physicians’ services provided to Medicare and Medicaid beneficiaries using the NPI numbers of physicians who neither provided nor personally supervised the services rendered. Other examples include Towson University Speech Language & Hearing Center, which paid $10,000 for submitting claims for audiology services with an NPI that did not correctly identify the provider who actually rendered those services; a family practice physician who paid $133,880 for submitting claims to Medicare for nurse practitioner services as though he had personally performed the services; a hospital that paid $706,090 in penalties for submitting claims for physicians’ services provided by a doctor to Medicare beneficiaries using the provider identification numbers of another doctor who did not furnish the services; and a medical school practice that paid $138,321 after it submitted claims for services provided by physicians to Medicare beneficiaries using the provider identification numbers of two physicians who did not furnish the services.

As a reminder, services generally must be billed under the name and NPI of the provider who actually performed the services. Billing under one provider’s name and NPI for services that are furnished by another provider may be fraudulent if the identity of the person performing the service would be material to the government’s decision to pay the claim.

The government does, however, permit the services of one provider to be billed under the name and NPI of another provider in certain limited circumstances, including where the services of auxiliary personnel (including both physicians and non-physician practitioners) are billed “incident-to” the professional services of a physician, and where the services of a substitute physician are billed under the regular, but unavailable, physician’s name and NPI on a temporary basis (“locum tenens” and “reciprocal billing” arrangements). These billing practices have very specific and stringent requirements, and failure to strictly comply with those requirements could subject providers to significant liability under the False Claims Act.

Importantly, the incident to, locum tenens, and reciprocal billing rules are Medicare rules and may not apply in the context of private payor billing. Many commercial plans specifically prohibit billing the services of one provider under the name and NPI of another provider and explicitly require that all services be billed under the name of the rendering provider. Providers billing private payors must therefore review their provider contracts and health plan rules to determine whether billing the services of one provider under the name and NPI of another provider is ever allowed, and if so, under what circumstances. If prohibited, knowingly billing under another provider’s name and NPI could potentially lead to criminal liability under the federal health care fraud statute, which makes it a crime to knowingly and willfully obtain by means of false or fraudulent representations money or property owned by any health care benefit program in connection with the delivery of or payment for health care services.

Key Takeaway

Before submitting bills for services furnished by one provider under the name and NPI of another provider, practices must be intimately familiar with the rules under which such billing is appropriate and allowed. Although practices that are under pressure to pay non-credentialed physicians may be able to bill the non-credentialed physician’s services under a credentialed physician’s NPI pursuant to Medicare incident to rules, such billing may be prohibited by commercial payors. Commercial payors also may not recognize locum tenens or reciprocal billing arrangements. In sum, billing under another provider’s name and NPI without strictly complying with CMS’s stringent incident-to or reciprocal billing rules, or in violation of private payor contracts, can spell big trouble, including treble damages under False Claims Act where claims are submitted to the government, and even criminal liability under the federal health care fraud statute.

Regulatory Alert: Share your concerns in MGMA’s 2018 Regulatory Relief Survey

Originally printed in the September 10th issue of MGMA’s Washington Connection. Reprinted by permission from MGMA.

MGMA’s 2018 Regulatory Relief Survey is your chance to voice your thoughts on the impact of federal government rules and requirements on your practice. As a practice leader, you know the most challenging regulations facing your practice, and we want to hear from you. The findings of this survey will help guide MGMA advocacy efforts in Washington to reduce those burdensome regulations on group practices.

Survey results will be shared at MGMA’s Annual Conference in Boston during the Regulatory Relief Forum. Don’t miss this chance to make an impact on the policies that matter to you most.

Questions?

Contact MGMA Government Affairs by e-mailing govaff@mgma.org or calling 202-293-3450 or toll free 877-275-6462.