Free September 10th GCHEG Webinar with Seema Verma of CMS

GCHEG Webinar with Seema Verma, Administrator of CMS
NCMGMA Members Invited to Attend at No Cost

September 10, 2020 | 10:45 AM – 12:00 PM EDT

On September 10th, the Greater Charlotte Healthcare Executives Group (GCHEG) will be hosting a live stream webinar with Seema Verma, Administrator, Centers for Medicare and Medicaid Services (CMS). GCHEG is holding this special event for not only the members of ACHE Chapter, GCHEG, but also for North Carolina’s healthcare professional community! There is no cost to attend.

Follow this link for online registration

Provider Relief Funds Deadline Extended to September 13th

The Centers for Medicare & Medicaid Services (CMS) announced the deadline for Medicaid/CHIP providers to submit their financial data to apply for federal Provider Relief Funds has been extended to Sept. 13, 2020.

Providers that have not yet submitted their applications are encouraged to apply. Providers who received payments from the Provider Relief Fund previously or had a change in ownership are now eligible to receive payments. More information is available in SPECIAL BULLETIN COVID-19 #126: New Deadline for Medicaid Providers Applying for Federal Relief Funds.

MGMA advocates for additional relief for physician practices, ACOs

Last week, Democratic leadership in the U.S. House of Representatives introduced the ‘‘Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act,” which includes several provisions that directly pertain to medical practices. The legislation would make further amendments to the PPP, Medicare’s Advance Payment Program, and the Provider Relief Fund. While this bill is not expected to pass due to lack of bipartisan support, MGMA offered several key recommendations for consideration as Congress works to come to a bipartisan agreement.

Additionally, MGMA and other industry-leading associations have urged the Centers for Medicare & Medicaid Services (CMS) to provide flexibility for practices participating in a Medicare accountable care organization (ACO) and to protect them from potentially harmful losses created by the COVID-19 pandemic. Specifically, MGMA called on CMS to:

• Adopt a policy to give ACOs an option to be protected from losses in exchange for a reduced shared savings rate, no less than 40%;
• Extend the current June 1 Medicare Shared Savings Program (MSSP) deadline to voluntarily terminate to avoid financial losses to no earlier than Oct. 31;
• Reverse its decision to cancel the 2021 MSSP application cycle; and

Pay ACO shared savings payments and advanced alternative payment model bonuses as soon as possible

Regulatory Alert: CMS Increases Telehealth Payments and Makes ACO Changes

Originally published on April 30, 2020 by MGMA
Reprinted with permission from MGMA

Today, the Centers for Medicare & Medicaid Services (CMS) issued another round of regulatory waivers through an interim final rule intended to expand care to Medicare beneficiaries and provide more flexibilities to the providers that treat them. The changes outlined below will be effective for the duration of the COVID-19 public health emergency (PHE).

Changes to telehealth policy:

• Following MGMA advocacy, CMS is increasing payment for audio-only telephone E/M services (CPT codes 99441-99443) such that they are paid at the same rate as similar office and outpatient E/M visits, resulting in increased payments from $14-$41 to $46-$110. CMS believes that the resources required to furnish these services during the PHE are better captured by RVUs associated with level 2-4 established office/outpatient E/M visits. CMS is not increasing payment for CPT codes 98966-98968, which are intended for practitioners that cannot separately bill for E/M. This policy is retroactive to March 1, 2020.
• For telehealth services other than CPT codes 99441-99443 and 98966-98968 (now added to the list of covered telehealth services), Medicare continues to require modalities that have both audio and video capabilities.
• CMS is forgoing its typical rulemaking process to add new services to the list of Medicare services that may be furnished via telehealth. Instead, CMS will add new telehealth services on a sub-regulatory basis to speed up the process of adding codes to the list.

Changes to Medicare Shared Savings Program (MSSP):

• There will be no application cycle for a Jan. 1, 2021 start date, and ACOs in the last performance year of their current agreement period (mainly Track 1 ACOs and Track 1+ Model ACOs) will be allowed to voluntarily extend their agreement period by an additional performance year in 2021.
• ACOs participating in the BASIC track glide path will be permitted to maintain their current risk level under the BASIC track for PY 2021 and freeze progression to higher risk.
• CMS is removing all Part A and B payment amounts for episodes of care involving the treatment of COVID-19 for the purposes of determining benchmark year and performance year expenditures.
• The list of primary care services used for beneficiary attribution will be expanded to include additional telemedicine services.

MGMA Government Affairs will continue to inform medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. CMS’ press release on the changes can be found here and a fact sheet on MSSP changes can be found here.

Extended 2019 MIPS data submission ends April 30, plus new 2020 COVID-19 improvement activity

The 2019 Merit-based Incentive Payment System (MIPS) data submission extension will end on April 30, 2020, at 8 pm. Individual MIPS eligible clinicians (ECs) who have not submitted any data, and who do not submit their MIPS data by the submission deadline will qualify for the 2019 automatic extreme and uncontrollable circumstances policy. MIPS ECs, groups, and virtual groups that submitted some data, but not able to complete their 2019 MIPS submission can now apply for a 2019 extreme and uncontrollable circumstances exception due to the COVID-19 pandemic.

The Centers for Medicare & Medicaid Services (CMS) also announced that ECs may now earn 2020 MIPS credit for participation in a clinical trial and reporting clinical information by attesting to the new COVID-19 Clinical Trials improvement activity. In order to receive credit for the new improvement activity, ECs must attest that they participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study.

Click Here to Read More

Regulatory Alert: CMS Announces New Flexibilities

Originally published on March 31, 2020 in MGMA’s Washington Connection
Reprinted with permission from MGMA

Last night, the Centers for Medicare & Medicaid Services (CMS) issued a series of temporary regulatory waivers to further support the ability of the nation’s healthcare system to respond to COVID-19. The changes outlined below will take effect immediately across the entire country:

• New telehealth codes. CMS will pay for 80 additional telehealth codes, including home visits, emergency department visits, and therapy services. Providers can waive copayments for all telehealth services for Original Medicare beneficiaries.
• Virtual check-ins. Clinicians can provide virtual check-in services (HCPCS G2012, G2010) to both new and established patients. Previously, these services were limited to established patients only.
• Telephone codes. CMS will reimburse for telephone evaluation and management services provided by a physician (CPT 99441-99443) and telephone assessment and management services provided by a qualified nonphysician healthcare professional (CPT 98966-98968). These codes are only available to established patients but may be furnished using audio-only devices.
• E-visits. Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits (HCPCS G2061-G2063). These codes are only available to established patients and must be initiated by the patient.
• Removal of frequency limitations on Medicare telehealth. Subsequent inpatient visits (CPT 99231-99233), subsequent skilled nursing visits (CPT 99307-99310), and critical care consult codes (CPT G0508-G0509) no longer have limitations on the number of times they can be billed.
• Medicare physician supervision requirements. Physician supervision can be provided virtually using real-time audio/visual technology for services requiring direct supervision by a physician or other practitioner.
• “Stark Law” waivers. CMS is implementing waivers that exempt providers from sanctions for noncompliance of certain Stark Law rules, permitting certain referrals and the submission of related claims that would otherwise violate the Stark Law.
• MIPS flexibilities. CMS will allow clinicians adversely affected by COVID-19 to submit an application to request reweighting of the MIPS performance categories for the 2019 performance year.

MGMA Government Affairs will continue to educate medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. For a comprehensive list of Medicare telehealth waivers and regulatory developments, please click here.

COVID-19 Regulatory Alert: CMS Announces Expanded Advance Payment Program to Provide Accelerated Loans to Healthcare Providers

Originally published in the March 30, 2020 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

On Saturday, the Centers for Medicare & Medicaid Services (CMS) announced nationwide expansion of the existing accelerated Advance Payment Program (APP), making the program available for most Medicare physicians and group practices. The APP provides a quick mechanism for healthcare entities to obtain accelerated, interest-free cash flow. Specifically, the APP fact sheet outlines that:

• Physician practices can request an advanced payment of up to 100% of the Medicare payment amount based on a three-month lookback period. Hospitals can request up to 100% (125% for critical access hospitals) based on a six-month lookback period. The guidance does not specify how the lookback period is determined.
• Healthcare entities must make a request for an accelerated payment under the APP by submitting a form to their Medicare Administrative Contractor (MAC).
• Once requested, CMS anticipates MACs will issue payment within seven calendar days from the request.
• The criteria for applying for the APP are:
  • Having billed Medicare for claims within 180 days immediately prior to the date of request;
  • Not in bankruptcy;
  • Not under active medical review or program integrity investigation; and
  • No outstanding delinquent Medicare overpayments.
• APP payments are subject to repayment, which for most healthcare entities begins 120 days after the payment is received.
  • During the 120-day period, the healthcare entity will continue to be paid like normal for claims submitted to Medicare.
  • After the 120 days, the recoupment process starts and every claim submitted will be offset to repay the advanced payment.

   

This announcement is a step in the right direction; however, MGMA is advocating that the Administration make available funding that is not subject to repayment or recoupment. Recently passed legislation (the CARES Act) creates several financial assistance programs, including $100 billion in grants for Medicare physicians and hospitals. Although the APP fact sheet states that the APP reflects the passage of the CARES Act, which did expand the APP, this program is not part of the $100 billion in funding authorized under that law.

Reminder: 2020 Only a Testing Year for AUC

Originally published in the January 16, 2020 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Some medical group practices have been told to immediately purchase and use Clinical Decision Support Mechanism (CDSM) software to comply with the Appropriate Use Criteria (AUC) program, with vendors suggesting that claims payment would be impacted in 2020. In a posting on its website, the Centers for Medicare & Medicaid Services (CMS) reiterated that 2020 is an educational and operational testing period and there are no payment consequences this year.

The AUC program will require ordering professionals to consult CDSM software for certain advanced imaging tests and require rendering professionals to include that consultation code on their Medicare claims starting in 2021. Practices are encouraged, however, to plan for implementation of CDSM software and test workflows at some point this year. Access the MGMA AUC Toolkit for additional information on the program.

Your Guide to 2020 Payment Rules & MIPS Requirements

Originally published in the November 20, 2019 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

It’s here! Your Guide to 2020 Payment Rules
& MIPS Requirements

DOWNLOAD MGMA’S MEMBER EXCLUSIVE ANALYSIS

The Centers for Medicare & Medicaid Services (CMS) released the final 2020 Physician Fee Schedule (PFS), which includes payment updates for Medicare services, changes to billing guidance for certain codes, and modifications to reporting requirements under the Merit-based Incentive Payment System (MIPS).

MGMA Government Affairs reviewed, analyzed, and distilled this nearly 2,500-page final rule in a member-benefit analysis. The resource breaks down significant payment and quality reporting changes for 2020 and offers practical takeaways for busy medical group practice executives. Key regulatory provisions include:

• The CY 2020 PFS conversion factor remains relatively flat at $36.0896. The CY 2020 national average anesthesia conversion factor will be $22.2016.
• In 2021, CMS will maintain separate payment rates for E/M office visits, delete level 1 office visits for new patients, and increase the payment rate for E/M services.
• Payment rates for transitional care management services will increase in CY 2020.
• The MIPS score to avoid a negative payment adjustment in 2022 will increase to 45 points based on performance in 2020.

MGMA will provide further education on this complex regulation during our 2020 Medicare Payment Outlook member-benefit webinar on Thursday, Dec. 5 at 1 pm ET. Register now to join us and learn more about how your organization can prepare for these new policies in 2020.

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.