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.

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.

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.

Issue Spotlight: Proposed Changes to Medicare E&M Visits

Originally published in the July 18, 2018 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

The Centers for Medicare & Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule proposed rule that would affect Medicare physician reimbursement policies beginning in 2019. Among other changes, CMS proposes to:

  • Collapse evaluation and management (E&M) Levels 2-5 into one level for new patients and another for established patients. The average national payment would be $135 for new patients and $93 for established patients.
  • Allow clinicians to choose to document office and outpatient E&M visits using medical decision-making or time or continue using the current 1995 or 1997 E&M documentation guidelines.
  • Create a minimum documentation standard so clinicians would only need to meet requirements currently associated with a level 2 visit for history, exam, or medical-decision making (except when using time to document the service).

To help MGMA evaluate the impact of these proposed changes and advocate on behalf of medical group practices, please share your feedback on these proposals by filling out this brief comment form.

MLN Connects: Thursday, February 15, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 15, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • MIPS Reporting Deadlines Fast Approaching: 10 Things to Do and Know
  • Quality Payment Program: Performance Scores for 2017 Claims Data
  • Diabetic Self-Management Training Accreditation Program: New Webpage and Helpdesk
  • Measures of Hospital Harm: Comment by February 16
  • EHR Incentive Program: Accepting Proposals for New Measures by June 29
  • New Option for Submission of Medicare Cost Reports

Provider Compliance

  • Home Health Care: Proper Certification Required — Reminder

Claims, Pricers & Codes

  • January 2018 OPPS Pricer File

Upcoming Events

  • Improving Accessibility of Provider Settings Webinar — February 21
  • ESRD QIP: Final Rule for CY 2018 Call — February 22
  • 2018 QCDR Measures Workgroup Webinar — February 27
  • Serving Adults with Disabilities on the Autism Spectrum Webinar — February 28
  • MIPS Quality Data Submission Webinar — February 28
  • Palliative and Hospice Care for Adults with Disabilities Webinar — March 7
  • Low Volume Appeals Settlement Option Update Call — March 13
  • Open Payments: The Program and Your Role Call — March 14
  • MIPS Attestation for Advancing Care Information and Improvement Activities Webinar — March 14

Medicare Learning Network Publications & Multimedia

  • Medicare Enrollment Resources Educational Tool — Revised
  • PECOS FAQs Booklet — Revised
  • PECOS for DMEPOS Suppliers Booklet — Revised
  • Safeguard Your Identity and Privacy Using PECOS Booklet —Revised
  • PECOS for Provider and Supplier Organizations Booklet — Revised
  • PECOS Technical Assistance Contact Information Fact Sheet — Revised
  • Health Professional Shortage Area Physician Bonus Program Fact Sheet — Revised
  • Medicare Secondary Payer Booklet – Reminder
    Beneficiaries in Custody under a Penal Authority Fact Sheet — Reminder

MLN Connects: Thursday, February 1, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 1, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • Medicare Diabetes Prevention Program: Supplier Enrollment Open
  • Targeted Probe and Educate: New Resources
  • MIPS Clinicians: 2017 Extreme and Uncontrollable Circumstances Policy
  • Quality Payment Program: Patient-facing Encounters Resources
  • Eligible Hospitals and CAHs: Get Help with Attestation on QNet
  • Find Medicare FFS Payment Regulations
  • February is American Heart Month

Provider Compliance

  • Cochlear Devices Replaced Without Cost: Bill Correctly — Reminder

Upcoming Events

  • eCQM Reporting for Hospital IQR-EHR Incentive Program Webinar — February 6
  • Low Volume Appeals Settlement Option Call — February 13

Medicare Learning Network Publications & Multimedia

  • Next Generation Accountable Care Organization – Implementation MLN Matters® Article — Revised
  • DMEPOS Quality Standards Educational Tool — Revised
  • Home Oxygen Therapy Booklet — Revised
  • Looking for Educational Materials?

MLN Connects: Thursday, January 18, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN).  Below is the latest news from Thursday, January 18th:

News & Announcements

  • 2018 Value Modifier Results and Payment Adjustment Factor
  • Final DMEPOS Quality Standards for Therapeutic Shoe Inserts
  • Glaucoma Awareness Month: Make a Resolution for Healthy Vision

Provider Compliance

  • CMS Provider Minute Video: CT Scans – Reminder

Upcoming Events

  • New Medicare Card Project Special Open Door Forum – January 23
  • ESRD QIP: Final Rule for CY 2018 Call – January 23
  • MIPS Annual Call for Measures and Activities Webinar – February 5
  • Comparative Billing Report on Opioid Prescribers Webinar – February 21

Medicare Learning Network Publications & Multimedia

  • QRUR Video Presentation – New
  • Low Volume Appeals Settlement Call: Audio Recording and Transcript – New
  • Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians Web-based Training – Revised
  • How to Use the Medicare Coverage Database Booklet – Revised
  • Behavioral Health Integration Services Fact Sheet – Revised