IT & Security Services for Medical Practices

The Department of Health and Human Services (HHS) announced proposed changes to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the “Stark Law”) and the Federal Anti-Kickback Statute.

The proposed rules provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposals would ease the compliance burden for healthcare providers across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse.

The proposed rules are part of HHS’s Regulatory Sprint to Coordinated Care, which seeks to promote value-based care by examining federal regulations that impede efforts among providers to better coordinate care for patients.

“President Trump has promised American patients a healthcare system with affordable, personalized care, a system that puts you in control, provides peace of mind, and treats you like a human being, not a number. But too often, government regulations have stood in the way of delivering that kind of care,” said HHS Secretary Alex Azar. “Regulatory reform has been a key piece of President Trump’s agenda not just for faster innovation and economic growth, but also better, higher-value healthcare. Our proposed rules would be an unprecedented opportunity for providers to work together to deliver the kind of high-value, coordinated care that patients deserve.”

“These proposed rules would be a historic reform of how healthcare is regulated in America,” said HHS Deputy Secretary Eric Hargan. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system, while maintaining the important protections patients need. Here at HHS, CMS and the Office of Inspector General recognized the need for reform and have acted to produce serious and thoughtful sets of proposals.”

The Stark Law’s new value-based exceptions, under the proposed rule issued by the Centers for Medicare & Medicaid Services (CMS), acknowledge that incentives are different in a healthcare system that pays for value, rather than the volume, of services provided. They include proper safeguards that ensure the Stark Law will continue to provide meaningful protection against overutilization and other harms, while giving physicians and other healthcare providers added flexibility to improve the quality of care for their patients.

“We serve patients poorly when government regulations gather dust in the attic: they become ever more stale and liable to wreak havoc throughout the healthcare system,” said CMS Administrator Seema Verma. “Administrative costs are driving up the cost of healthcare in America – to the tune of hundreds of billions of dollars. The Stark proposed rule is an important next step in President Trump’s healthcare agenda for Americans. We are updating our antiquated regulations to decrease burden for providers and helping bring down these increasingly escalating costs.”

The proposed changes to the regulations related to the Federal Anti-Kickback Statute and the Civil Monetary Penalties Law issued by the Office of Inspector General (OIG) would, if finalized, address the longstanding concern these laws unnecessarily limit the ways in which healthcare providers can coordinate care for patients. The changes would offer flexibility for beneficial innovation and improved coordinated care through, for example, outcome-based payment arrangements that reward improvements in patient health. The changes would also make it easier for physicians and other healthcare providers to ensure they are complying with the law by offering specific safe harbors for these arrangements.

“Any patient can tell you how difficult it is to coordinate their own care. This proposed rule would help patients to focus on their health, enable providers to better coordinate high-quality healthcare, and empower both to achieve improved health outcomes,” said Acting Inspector General Joanne M. Chiedi. “We are proposing strong safeguards to protect patients from fraud and abuse by bad actors who might seek to misuse the new flexibilities.”

Below are examples involving coordinated care, value-based care, data sharing, and patient engagement activities that, depending on the facts, could currently be difficult to fit under existing protections and could potentially be protected by the Stark Law, Anti-Kickback Statute, or Civil Monetary Penalties Law proposals if all applicable conditions are met:

• In an effort to coordinate care and better manage the care of their shared patients, a specialty physician practice could share data analytics services with a primary care physician practice.
• Hospitals and physicians could work together in new ways to coordinate care for patients being discharged from the hospital. The hospital might provide the discharged patients’ physicians with care coordinators to ensure patients receive appropriate follow up care, data analytics systems to help physicians ensure that their patients are achieving better health outcomes, and remote monitoring technology to alert physicians or caregivers when a patient needs healthcare intervention to prevent unnecessary ER visits and readmissions.
• A physician practice could provide smart pillboxes to patients without charge to help them remember to take their medications on time. The practice could also provide a home health aide to teach the patient and the patient’s caregiver how to use the pillbox. The pillbox could automatically alert the physician practice and caregiver when a patient misses a dose so they could follow up promptly with the patient.
• A local hospital could improve its cybersecurity and the cybersecurity of nearby providers that it works with frequently. To do so, it could donate, for free, cybersecurity software to each physician that refers patients to its hospital. The hospital and the physicians often share information about their patients, so it is important that there are no weak links that might compromise everyone else. The software would help ensure that hackers cannot attack the physician’s computers. Improving each physician’s cybersecurity would help prevent hackers from spreading the attack to other physicians and the hospital.
• To improve health outcomes for patients with end-stage kidney disease, a nephrologist, dialysis facility, or other provider could furnish the patients with technology that is capable of monitoring the patient’s health and two-way, real-time interactive communication between the patient, facility, and physician. In addition, the facility could equip the physicians with data analytics software to help them monitor patients’ health outcomes.

Writing off patient copays may be well-intended, but this generosity can have costly consequences. Write-offs may be hurting your practice by compromising your contracts with private payers. Violating these terms of your contract may negatively affect reimbursements from those payers. You may even be found guilty of a felony if the patient is enrolled in Medicare or Medicaid. The repercussions of said felony are: up to five years in prison, criminal penalty of up to $25,000, administrative penalty of up to $50,000, triple damages, and permanent exclusion from these programs. These risks are avoidable providing you follow the proper channels to help your patients with their out-of-pocket expenses.

There are several reasons why waiving copays could be a problem. It is harder for payers to enter into contracts when practices are undervaluing their services by writing off patient copays or deductibles. Copays being a part of the contract between provider and payer, waiving them can be a breach of contract resulting in civil lawsuits, compensatory damages, and loss of additional contracts. Payers use copays to prevent overuse of services, so waiving patient charges may be seen as encouragement to use more services, effectively increasing the payers’ costs. Other possible consequences include violation of a number of statues including the Anti-Kickback Statute (AKS), Civil Monetary Penalties Law (CMPL), and Stark Law. For Medicare or Medicaid patients, you could find yourself in violation of the AKS wherein waiving copays and deductibles may be seen as bribing patients to seek your services instead of going to another practice. Violations of the AKS are penalized by $5,500 to $11,000 per claim and repayment of the funds your practice erroneously received. Your practice would be guilty of breaking the CMPL if waiving a Medicare copay induces the patient to seek specific services or medical equipment from your provider or another by your recommendation. Influencing a patient to seek services from a specialist or provider your practice is associated with by waiving out-of-pocket expenses is a violation of the Stark Law.

Despite the penalties for erroneously waiving copays, practices should not be dissuaded from assisting Medicare and Medicaid patients when situations of financial hardship arise. When you have evidence supporting a patient’s financial need, there are exceptions to the AKS and CMPL that provide proper channels for forgiving patient responsibility. Poof that the write-off is not an inducement to seek services or equipment from you or an affiliate is necessary to ensure that the write-off is legitimate. Additionally, you may need to provide evidence that your office is not waiving copays and deductibles regularly to avoid violations and penalties. Your practice should have an established policy that outlines the circumstances in which it is and is not appropriate to forgive a patient’s out-of-pocket expenses. Documentation should be kept in patient files as proof of the financial circumstances supporting your decision to waive patient responsibility per your policy. Your policy and documentation will benefit all parties, upholding your contracts, safeguarding your practice, and providing financial assistance to your patients.

CMS.gov. “Medicare Fraud & Abuse: Prevent, Detect, Report.” MLN Booklet , Centers for Medicare & Medicaid Services, Feb. 2019, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf .

NHIC, Corp. “Improper waivers.” Fraud & Abuse Guide, Centers for Medicare & Medicaid Services, 5^th ed., Oct. 2007, pp. 13-15, https://cdn.ymaws.com/www.aahcm.org/resource/resmgr/2007_fraud_policy.pdf.

Pegg, Bruce. “Know When You Can – and Cannot – Waive Patient Copays.” AAPC Knowledge Center , American Academy of Professional Coders (AAPC), 4 Sept. 2019, https://www.aapc.com48289-know-when-you-can-and-cannot-waive-patient-copays/.

HMS will begin auditing Medicare Plus Blue PPO’s reimbursed diagnosis-related group claims for clinical and coding validation, starting Sept. 1, 2019. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure claims were billed in accordance with coding guidelines, and diagnoses were supported by documentation in the medical record.

Be ready to share medical charts for review. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

The purpose of the clinical audit of the diagnosis-related group, or DRG, is to:

• Confirm compliance with national coding guidelines.
• Ensure documentation supports diagnoses and procedures reported.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payments.

HMS will be holding webinars for providers with information on the overall DRG clinical validation process and helpful tips. Schedules will be provided in a future web-DENIS message.

DRG clinical validation audits take a three-phase approach. See the scope of each phase and the data period for each phase in the chart below.

Effective Sept. 1, 2019, through Aug. 31, 2020, value-based reimbursement for the Patient-Centered Medical Home designation will increase from 110% to 115%.

The temporary change recognizes that PCMH value-based reimbursement has remained at the same level for 10 years, but the expectations have become more rigorous over time and continue to evolve.

As part of the continued evolution of the program, we encourage PCMH practices to collaborate with their physician organizations to:

• Adopt more advanced PCMH capabilities
• Use care managers or care teams and the health information exchange to improve care coordination

Value-based reimbursement for PCMH designation will return to 110%, effective Sept. 1, 2020. The additional 5% value-based reimbursement will be reallocated from PCMH to the Provider-Delivered Care Management program for primary care physicians.

We’ll be communicating about these changes in future issues of The Record.

If you have any questions about these changes, contact your PGIP physician organization.

In 2011, the Centers for Medicare & Medicaid Services (CMS) terminated their use of consultation codes. They created a crosswalk system to transition providers away from using these eliminated codes. Office/outpatient Evaluation & Management (E/M) codes 99211-99205 replaced consult codes 99241-99245. Initial hospital care codes 99221-99205 replaced 99251-99255.

This shift resulted in lower reimbursement because the Relative Value Units (RVUs) for non-consult codes are significantly lower than those of the eliminated consult codes. Other payers still accepted the consult codes, causing confusion over inpatient consult codes being replaced with initial hospital care codes. The new AI (principal physician of record) modifier created confusion as well. The AI modifier was to be appended by admitting physicians so that specialists doing consultations could report initial hospital care codes on the same day. However, many didn’t use the modifier resulting in denials for duplicate services.

Training was provided to fix these issues, but physicians still had a decision to make. They had to decide if they would continue documenting the additional information required for consult codes that other E/M codes don’t need. This additional information includes: requesting provider, reason for consult, report of results, and recommended treatment. Some providers liked these details because they help to differentiate consult and transfer of care situations. Others preferred to omit these extra details because they viewed them as more work for less reimbursement in the end.

UnitedHealth announced in March of 2019 that they would be updating fee schedules to align more with Medicare. They will be eliminating the consult codes in congruence with the CMS. Cigna announced the same in July of 2019 that they would be implementing a new reimbursement policy. Their deadline is October 19, 2019, after which CPT consultation codes will not be valid. Though claims rejected for this reason may be resubmitted with the appropriate non-consultation E/M code. This update for both UnitedHealth and Cigna reflect their private plans. Any Medicare Advantage plans eliminated consult codes back in 2011. This is a big change for practices used to commercial insurances.

Two major commercial payers will stop reimbursing consultation E/M services (CPT codes 99241-99255) in October, finally joining CMS in ditching the high-paying but sometimes confusing code set.

UnitedHealth made its announcement in its March 2019 newsletter, stating that it was aligning its policy to match Medicare’s as part of an effort to shift participating providers to “more current fee schedules.” UnitedHealth will stop recognizing and paying for consults on Oct. 1, 2019.

Cigna’s announcement came more recently in a July bulletin but the company offered no specific explanation. “We will implement a new reimbursement policy, Evaluation and Management (R30), and deny claims billed with CPT consultation codes as not valid,” Cigna writes in the bulletin. “Claims can be resubmitted with the appropriate non-consultative E/M code that describes the service.” Cigna will stop recognizing and paying for consults a little later than UnitedHealth, on Oct. 19, 2019.

Read the full blog post from The DoctorsManagement Compliance Team.

In April 2018, Medicare began the process of removing Social Security Numbers from Medicare cards in an effort to prevent identity theft. Health Insurance Claim Numbers (HICNs) were replaced by Medicare Beneficiary Identifiers (MBIs), randomly generated combinations of 11 alphanumeric characters. The MBI is confidential and should be protected like any other Personally Identifiable Information.

These new Medicare cards were sent out between April 2018 and April 2019. During the 21 month transition period, providers have been able to continue filing claims using HICNs. This transition from HICN to MBI will be complete at the end of December 2019. Beginning in January 2020, Medicare claims must be submitted using MBIs no matter the date of service. HICNs will no longer be accepted after January 1, 2020 and claims submitted with the HICNs will be rejected.

There are a few exceptions to this rule:

• Appeals: HICNs or MBIs can be used for appeals or related paperwork.
• Claim status query: Either ID number can be used to check the status of a claim if the earliest DOS is before January 1, 2020. MBIs must be used for claims with DOS after January 1, 2020.
• Span-date claims: Either number can be used for 11X-Inpatient Hospital, 32X-Home Health and 41X-Religious Non-Medical Health Care Institution claims as long as the “From Date” is before December 31, 2019. If a patient’s services begin before December 31, 2019 and continue until after December 31, 2019, the claim can be submitted with either the HICN or MBI even if it is submitted after the deadline. Because home health claims are submitted for 60-day payment periods, providers can send them in with either the HICN or MBI. However, once the December 31, 2019 deadline is passed, the MBI must be used on the final claim that goes with these home health claims.

For more information, visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareCard-FactSheet-TextOnly-909365.pdf

CMS announced a new pilot program for practices called Data at the Point of Care (DPC). The DPC pilot is based on application programming interface (API) standards and is part of the CMS MyHealthEData initiative. The pilot will provide practices access to Medicare claims data directly within their workflow such as previous diagnoses, past procedures, and medication lists without needing to log into another application. Pilot participants will receive a beneficiary’s claims data including data from other treating providers. To participate in the pilot, practices must have an EHR that is API enabled, and CMS is especially interested in working with those who already receive claims data from other payers and have integrated the information into their existing workflow. Those interested in participating in the DPC pilot program can sign up here.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required CMS to develop patient relationship codes to attribute patients and episodes of care to clinicians for purposes of cost measurement in MIPS. Beginning in 2018, clinicians began to voluntarily include patient relationship modifiers on claims to describe their treatment relationship with the patient (i.e., the reporting clinician provides continuous services to the patient and provides principal care; the reporting clinician performs episodic and focused services and provides time-limited care). To incentivize reporting of these codes, CMS proposes a new high-weighted MIPS improvement activity that would award credit to clinicians or group practices that report patient relationship modifiers starting in 2020. For more information, review CMS’ recently released resource on patient relationship code reporting.

MGMA has developed a member-exclusive comprehensive analysis of the 2020 Medicare physician fee schedule proposed rule, which includes changes to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) policies. This is your definitive resource for understanding how potential changes to Medicare quality reporting and payment policies in 2020 may impact your practice. The analysis includes a review of policy proposals that would:

• Establish a conversion factor (i.e., the amount paid per relative value unit under the fee schedule) of $36.089;
• Revise documentation, billing, and payment for Medicare E/M services starting in CY 2021;
• Increase payment for transitional care management services; and
• Set reporting criteria to earn a bonus and avoid a payment cut under MIPS.

Medicare is currently having issues with processing incoming and outgoing files. The delay is in reguards to 835, 277, and 277CA Medicare J8 Part A and Part B, J5 Part B and J5 National lines of business. The issue will cause a delay in payment.

View the announcement.