DHHS NC Medicaid Transformation Seven-Year Forecast

The Department of Health and Human Services has delivered its North Carolina Medicaid Transformation Seven-Year Forecast legislative report, required by Session Law 2018-5 Section 11H.9, to the General Assembly and its Fiscal Research Division. This report provides a detailed forecast for the transition to Medicaid managed care for state fiscal years 2019 to 2025. For a brief summary of the report, an Executive Summary is included.

NCMGMA Boasts Largest Advocacy Days Ever!

With over 115 attendees in-house on Wednesday, NCMGMA celebrated our largest-ever Advocacy Days event. Our speaker lineup this year included Attorney General Josh Stein; Chip Baggett, NCMS; Cody Hand, NCHS; NC State Treasurer Dale Folwell; Dr. Mandy Cohen, DHHS; and a panel that include four of the newest Medicaid Managed Care payors. Our speakers and panelists brought our attendees up-to-date on everything from the State Health Plan to the latest happenings with Medicaid Managed Care.

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And just this morning, over 40 members set out to meet with their representatives at the North Carolina General Assembly to discuss important healthcare issues including:

  • Joint HHS Appropriations Committee for Medicaid Managed Care and the importance of awareness of the additional requirements now shifting to the providers due to multiple types of Insurance Carriers. Additionally, changes to the Fee for Service contracts moving to value-based care contracts and the administrative burden shifting to providers.
  • The Save Act asking providers not to vote for this bill as supervision from physicians is necessary to maintain the highest quality of care for our NC residents.
  • HB184 – Study of State Health Plan Design, asking to keep the bill as it currently is until more definite options are in place for quality and cost savings for the members and tax payers.
  • S886 – In favor of the Small Business Healthcare Act reducing employees from 26 to 12.

Thank you to all who came out for this year’s Advocacy Days, and a big thank you to Melissa White and Cam Cox, NCMGMA’s Advocacy Days co-chairs, for all their hard work in putting this event together for our members!

2019 NCMGMA Annual Conference

ac19-themepic300aDon’t forget to join us in Wilmington, May 8-10, 2019, for NCMGMA’s Annual Conference to network and receive additional advocacy updates, including:

  • A session on the Blue Premier Update from BCBSNC’s Mark Werner
  • “The Health of Healthcare Politics in NC” from Representative Dr. Murphy and Representative Josh Dobson
  • The “State of Change” with Nathan Babcock of Parker Poe
  • And More!

Click here to view the complete list of conference sessions and to start making plans to join your colleagues in Wilmington in May.

New Medicare Cards: It’s Zero Not O

Originally published in the February 27, 2019 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

In response to MGMA member concerns whether new Medicare Beneficiary Identifiers (MBIs) contain the number “0” or the letter “O” on new Medicare cards, CMS clarified that the MBI uses numbers 0-9 and all uppercase letters except for S, L, O, I, B, and Z. As a reminder, starting Jan. 1, 2020, Medicare will only accept the MBI on claims, and practices can access their MBIs via your Medicare Administrative Contractor web portal. Download the member-benefit New Medicare Card Toolkit for additional information on the transition to the new cards and numbers.

Speak Out for NC Healthcare March 13-14 in Raleigh


Speak out for patients, physicians and the business of healthcare in North Carolina

This year, join us March 13th and 14th in Raleigh as we host our annual Advocacy Days which we promise to be packed full of information you cannot afford to miss! There is no shortage of issues at hand in North Carolina and NOW is the time to make our voices heard! Register today!

Schedule of Events

Wednesday
March 13, 2019
11:00 AM – 5:30 PM
Legislative Program Sessions Include: 
Josh Stein, North Carolina Attorney General
Join us for a candid discussion as the NC Attorney General, Josh Stein, updates NCMGMA membership on how the Department of Justice is working to protect the business of North Carolina’s healthcare industry including updates on medical marijuana and the current opioid crisis.
Bowtie Briefing LIVE
Chip Baggett, North Carolina Medical Society

Always a fan favorite, hear about the many hot topics affecting medical practices in North Carolina. Chip Baggett will provide the group with insight into all that is happening in downtown Raleigh during the current session.
Dale Folwell, State Treasurer of North Carolina
Mr. Folwell will present on high-priority items including reimbursement changes for State Health Plan patients, the state’s relationship with Blue Cross, and the cost-saving measures the treasury department has demanded. Don’t miss this opportunity to talk to the Treasurer face-to-face about how the proposed fee schedule will impact your practice!
Dr. Mandy Cohen, NC Department of Health & Human Services
Hear the latest updates on Medicaid transformation and the critical timelines you need to know as the program moves forward. As DHHS plans to announce their selections for PHP insurers in February, we will be prepared to ask questions onsite about the carriers that will administer Medicaid benefits and claims adjudication, as well as the state’s role in overseeing the contracting and credentialing process and ensuring carrier compliance.

Cody Hand
Senior VP, Advocacy & Policy; Deputy General Counsel
North Carolina Healthcare Association

More to come!
5:30 PM – 7:00 PM
Networking Reception
Sponsored by Medical Mutual
Join fellow Advocacy Day attendees, speakers and sponsors for an evening of fellowship and networking before we
gear up for Thursday’s assembly meetings and legislative visits.
Thursday
March 14, 2019
9:00 AM – 12:00 PM
Organized Legislative Visits and General Assembly Meetings

Speakers

Josh Stein
Attorney General
North Carolina Department of Justice
Josh Stein was sworn in as North Carolina’s 50th Attorney General on January 1, 2017. Stein is focused on protecting North Carolina families from crime and consumer fraud.

Stein has made combating the opioid crisis a top priority. His office drafted the STOP Act to reduce the number of people who become addicted to opioids through smarter prescribing practices and the Synthetic Opioid Control Act, closing loopholes in state criminal law concerning fentanyl. Both laws passed the General Assembly unanimously and were signed into law by the Governor.

Prior to being elected Attorney General, Stein served as a state Senator and as a Senior Deputy Attorney General in the North Carolina Department of Justice. In the State Senate, Stein successfully led efforts to put more violent criminals behind bars by expanding the state’s DNA database. Stein wrote the School Safety Act and legislation that banned stalking using GPS tracking devices.

Chip Baggett, Juris Doctor
Senior Vice President, Advocacy and Advancement
Associate General Counsel
North Carolina Medical Society

In his capacity as Senior Vice President for Advocacy and Advancement Associate General Counsel, Chip is responsible for state level advocacy efforts (primarily focused on the NC General Assembly) as well as communications and fundraising for the NCMS and NCMS Foundation.

Chip has a long history in organizational advancement and advocacy. Dating back to college, he has fundraised in numerous paid as well as volunteer capacities. He has led successful corporate and personal annual fund programs and gone through training at the Indiana School of Fundraising. Chip has worked in many different facets of health care ranging from a children’s science and health museum and pharmaceutical sales before going to work directly for physicians and PAs as a medical society executive, first at the county level and then here at NCMS.

Dale Folwell, CPA
Treasurer
The State of North Carolina

Dale R. Folwell, CPA was sworn in as State Treasurer of North Carolina in January 2017. As the keeper of the public purse, Treasurer Folwell is responsible for a $100 billion state pension fund that provides retirement benefits for more than 900,000 teachers, law enforcement officers, and other public workers.

Under Folwell’s leadership, the pension plan was rated among the top five highest-funded in the country and won accolades for proactive management and funding discipline. In 2018 the state’s coveted AAA bond rating was reaffirmed by every major rating agency, making North Carolina one of only 13 states in the country to hold that distinction. Treasurer Folwell also oversees the State Health Plan, which provides medical and pharmaceutical benefits to more than 720,000 current and retired public employees and is the largest purchaser of health care in North Carolina.

Mandy Cohen, MD, MPH
Secretary
NC Dept. of Health and Human Services

Since being appointed as Secretary of the N.C. Department of Health and Human Services in January 2017, Mandy Cohen, MD, MPH, and her team have worked tirelessly to improve the health safety and well-being of North Carolinians. DHHS is a cabinet-level agency with approximately 16,000 employees and an annual budget of $20 billion. Among her top priorities are combating the opioid crisis, building a strong, efficient Medicaid program, and improving early childhood education.

A graduate of Cornell University, she received her medical degree from Yale School of Medicine, a Master’s in Public Health from the Harvard School of Public Health and trained in Internal Medicine at Massachusetts General Hospital.

Here is what others said about
NCMGMA’s Advocacy Days:

 “Pertinent and timely issues impacting the practice due to legislation passed,
Medicaid, and State Health Plan.”

“Excellent. Speakers were great and relative to all that is happening in NC right now.
Well worth the time and money. Dinner was delicious!”

“I wanted to learn more about Medicaid and was extremely pleased. I wish
I had planned to stay for the Legislative day, next year – I will!”

Registration

Registration
Advocacy Days registration includes educational sessions, lunch and Medical Mutual reception on Wednesday, March 13th, and organized legislative visits on March 14th. The cost to register is $95 for NCMGMA members, $125 for non-members and $45 for students. The early registration cutoff is February 27th. After 2/27, the cost of registration increases $20 per person for members and non-members, and $10 per person for students.

General Information

Hotel Accommodations
Reserve your room now at the Raleigh Marriott City Center. Limited standard rooms are available at the discounted rate of $189/night for single/double occupancy plus tax. To reserve your hotel room, please call the hotel directly at 1 (888) 236-2427. Guests making such reservations must identify themselves as members of the NCMGMA. All reservations must be accompanied by a first night room deposit or guaranteed with a major credit card. If a guest does not cancel a reservation within 48 hours before 6:00 PM of the guest’s check-in date, then Hotel may charge the credit card one night’s room fee plus any applicable taxes.

Cancellation Policy
Registration cancellations must be received in writing. Cancellations received on or before 5:00 PM on March 5th are entitled to a full refund less a $25 processing fee. No refunds will be awarded for cancellations after 3/5 or for no-shows.

Questions?
If you have any questions about the NCMGMA Advocacy Days, please contact the NCMGMA offices at 800-753-MGMA (6462) or by email at info@ncmgm.org.

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.