MIPS Audits Are Here: What You Need to Know

Beginning this month, Centers for Medicare and Medicaid Services (CMS) will conduct data validation and audits of a select number of Merit-based Incentive Payment System (MIPS) eligible clinicians for performance years 2017 and 2018. Practices targeted will receive a request for information from CMS’ contractor Guidehouse via certified mail or email. Those selected for audit will have 45 days from the date of the notice to provide the requested information.

If your practice is selected for an audit, you are encouraged to share your experience with MGMA. We will use this information to identify challenges practices face during the audit process and share concerns and recommendations directly with CMS. Visit the QPP Resource Library for information on the criteria for data validation for both performance years 2017 and 2018.

Article provided by the Medical Group Management Association.

An audit is a process of review for accuracy and efficiency based on regulations and procedures. Audits help identify billing and coding issues before they escalate, which allows medical practices to rectify errors before they are subject to government repercussions and fees. An audit can be conducted internally or externally and may be done pre-bill or post-bill.

Why are Audits Important?

Audits are conducted to ensure that coding is done according to regulations, claims are billed accurately and documentation supports the coding. They are also helpful tools to show areas where further training and improvement are necessary.

What is Typically Audited?

Certified Professional Coders (CPCs) can help your practice identify risk areas and make those the focus. They will consider past audits, weak areas, new procedures, new employees, etc. A narrow scope for the audit, which targets specific areas and periods, can help your practice find deficiencies and make plans for improvement.

How are Audits Conducted?

Once the auditors have identified what is to be reviewed, they will define the objectives of the audit and run a report under that scope. Typically, the process involves:

Yeo & Yeo Medical Billing & Consulting offers both on-site and remote auditing services. We have Certified Professional Coders on-site that are experienced in performing audits for a variety of practice sizes and specialties. If you have questions regarding our audit services or would like to schedule an audit, please contact us.

Refrence: Smith, Amy Lee. “Audit to Promote Revenue Integrity.” Healthcare Business Monthly, 1 Mar. 2019, pp. 44–47.

The Two-Midnight rule was established in October 2013. According to the fact sheet released by The Centers for Medicare and Medicaid Services, the rule states that inpatient procedures will be payable under Medicare Part A if the patient is expected to require a hospital stay that spans across two midnights.

For the rule to apply, the procedures must be medically necessary, and medical records need to support this if it is the case. However, payment for Part A is not appropriate if the stay lasts less than two midnights.

The goal of this rule is to cut back on medically unnecessary hospital admissions and the associated costs. Often, the cost of a procedure is higher for inpatient admissions than outpatient. Higher costs affect Medicare payment rates as well as patient costs.

The rule was revised to allow some flexibility for cases that qualify as exceptions, such as:

• If the case requires procedures on the inpatient-only list.
• The case is identified as a “rare and unusual exception” to the rule.
• When the doctor expects the patient to require a stay of at least two midnights, but the stay is cut short due to unforeseen circumstances such as death, transfer, improvement or release against medical advice.

A provider may decide that it is medically necessary for a patient to be admitted even though they are not expected to stay inpatient for two midnights. A patient should not be held in observation status for three or more days when admission is more appropriate for the patient’s care.

For more information on the updated Two-Midnight rule, see the CMS fact sheet.

Medicare for All proposes to expand the current Medicare system to cover more than just those 65 or older. Universal healthcare structures are employed in many other countries, and the concept has been discussed in the United States several times over the years. Lawmakers presented their first proposal for Medicare for All at the end of April 2019.

Medicare for All legislation would convert the U.S. health system to a single-payer structure administered by the Department of Health and Human Services.

Expected Benefits

This healthcare structure would provide coverage and benefits for all citizens with no deductibles or copays. Instead, it would take the premiums from employment-based plans and move them to the government. It is thought that this would reduce the cost of administration over said plans as well as lower prescription costs.

What’s the Catch?

Any change of this magnitude would take a considerable amount of time and effort to transition. However, some lawmakers believe we need to change the system and change it soon so that patients don’t have the burden of medical bills. Republican lawmakers worry that a change like this will take away the people’s choices of insurance, employer coverage and may deteriorate or eliminate programs for seniors.

Potential Costs

While many Democrats address the need for universal healthcare, professionals also posed many questions about how much Medicare for All will cost the United States. Our current system costs more than healthcare systems in many other countries. The new system proposed by Medicare for All legislation may increase cost in some areas while reducing it in others.

It is estimated to cost around $33 to 39 trillion, 11-13% of the GPD, in the first ten years, according to researchers at George Mason University. In addition to this cost, other unknown economic factors stand in the way. With numbers like these, professionals believe that doubling income tax would not cover the funds for a change this big.

The current debate is weighing the pros and cons of each outcome and the possible effects. As of yet, there is no clear solution.

The House of Representatives and the Senate have unveiled dueling legislation aimed at surprise billing, and the two are split on one key element: arbitration.

The House bill (PDF), which was introduced earlier this week by Reps. Frank Pallone, D-New Jersey and Greg Walden, R-Oregon, would require insurers to cover out-of-network emergency care at in-network rates and would ban balance billing.

Balance billing most often occurs in emergency departments or during elective surgery, when a patient goes to an in-network facility but is treated by an out-of-network clinician, typically an anesthesiologist or radiologist.

The Senate’s bill, however—which is backed by Sens. Bill Cassidy, R-Louisiana, and Maggie Hassan, D-New Hampshire—would include a “baseball-style” arbitration program to mitigate disputes, alongside similar elements to the House iteration.

In a statement, Cassidy, who is a physician himself, said the bipartisan working group has been developing the bill with input from providers, insurers and patient groups for more than a year. “Patients should be the reason for care, not an excuse for a bill,” he said.

The bills were introduced following a call to action from President Donald Trump, who last week gave a speech pushing Congress to address surprise billing. Senior White House officials told reporters that the administration has reservations about arbitration but was open to other solutions, such as using bundled payments.

Trump issued a series of guidelines for legislators to consider when developing bills, such as preventing an increase in healthcare expenditures and ensuring patients aren’t sent for out-of-network elective care without their knowledge.

Arbitration is used in New York, and a recent study found that consumer complaints about balance billing declined significantly in the state as a result. Providers in the state were more enthusiastic about the program than insurers, but case winners were evenly split between the two.

There are still improvements that could be made to New York’s arbitration approach, according to the study. For one, it doesn’t take steps to improve consumer insurance literacy and it also does not apply to self-insured plans, as those are exempted by the Employee Retirement Income Security Act regulations.

Surprise billing has been a hot-button topic in Washington, but work in the federal legislature has been slow-moving amid pushback from the provider and insurance lobbies. Sen. Lamar Alexander, R-Tennessee, who chairs the Senate Health, Education, Labor and Pensions Committee, told the president last week to expect action by July.

Article provided by Fierce Healthcare.

The Merit-based Incentive Payment System (MIPS) is a program that evaluates and rewards participating providers based on data reported in four performance categories: Quality, Promoting Interoperability, Cost, and Improvement Activities.

Starting in June 2019, Humana Medicare Advantage plans will use MIPS payment adjustment rates when reimbursing out-of-network clinicians that participate in MIPS for covered professional services. MIPS-eligible claims for services dates beginning January 1, 2019, that were processed before June 2019 will be reprocessed. The appropriate MIPS payment adjustment will then be retroactively applied to these claims.

For more information about MIPS and the Quality Payment Program, follow the link to our overview article, QPP Final Rule 2019 or visit https://qpp.cms.gov. For questions about Humana’s policy update, call Humana’s customer service at 1-800-457-4708.

The Centers for Medicare & Medicaid Services (CMS) published a toolkit highlighting strategies that Medicare accountable care organizations (ACOs) can use to coordinate care for their patient populations. The toolkit outlines strategies that include both system-wide initiatives and targeted interventions that support individuals with chronic conditions or recent acute care needs. The toolkit also includes examples of facilitating data exchange between primary care providers and emergency departments, establishing networks of post-acute care partners to support their mission of improving the quality and effectiveness of care, and focusing on information technology to streamline referrals to community organizations.

Article provided by MGMA Washington Connection 

CMS is launching a volunteer program for providers to test the process for reviewing compliance with HIPAA electronic transactions, unique identifiers, and operating rules among providers. Any providers who conduct electronic health care transactions can volunteer for the program on behalf of themselves or their group practice or hospital. CMS will select three healthcare providers from the pool of volunteers to work one-on-one with CMS to identify and resolve compliance issues. CMS estimates the testing will require a commitment of less than ten hours. Upon completion of the pilot program, participants will receive a certificate and will be exempt from compliance reviews for one year. Click here for more information on the program and how to contact CMS to volunteer. Contact CMS by April 24 to volunteer for the program.

Article provided by MGMA Washington Connection

MGMA joined more than 20 provider organizations in supporting newly introduced legislation that would remove regulatory barriers to value-based care delivery. The Medicare Care Coordination Improvement Act of 2019 (S. 966/H.R. 2282) would allow physician group practices additional flexibility to develop and test innovative payment and care delivery arrangements in value-based care models. The changes would track those currently implemented to accommodate ACOs. MGMA encourages members to urge their congressional representatives to co-sponsor this legislation via the “Contact Congress” portal above.

Article provided by MGMA Washington Connection

The Michigan Department of Health and Human Services (MDHHS) Third Party Liability Division (TPL) partners with commercial health insurance companies to receive their coverage information. This information is directly verified with their official eligibility source. Each insurance company assures that policies in CHAMPS are reported exactly as they are needed to submit claims.

The insurance companies who currently report coverage directly to TPL include BCN, BCBSM, McLaren, Priority Health, Administration Systems Research, Physician’s Health Plan, Medimpact, Express Scripts, OptumRX and Delta Dental. TPL will not change the format of policy information for these payers. Please do not submit this type of request, including the following examples:

• Adding or removing the alpha prefix for BCBSM coverage or other insurance companies
• Terminating McLaren coverage based on the legacy system web portal when it is continuing on the new system web portal
• Adding or removing hyphens and/or leading 0s from group numbers or policy numbers for Delta Dental, ASR, EHIM or other insurance companies

If providers determine coverage is being reported incorrectly by these insurance companies, please contact them to update their records. If the insurance company makes corrections, they will also send the update to TPL.

Source: Michigan Department of Health and Human Services

The AMA’s CPT Editorial Panel approved sweeping changes to documentation and code selection guidelines for evaluation and management codes.

If finalized, the changes would shift the way practices select codes for both office and facility visits as soon as January 2021.

Approved changes include:

• Deleting level 1 office new patient E/M code 99201.
• Removing history and exam as key components for selection of the E/M service level. The practitioner would be required to document that these elements were performed in order to report an office visit code.
• Practitioners would select E/M codes based on either 1) the level of medical decision making (MDM) or 2) the total time spent performing the service on the day of the encounter.
• A plan to revise the E/M guidelines into three sections:
  • Guidelines common to all E/M services
  • Guidelines specific to office and other outpatient visits
  • Guidelines specific to E/M services in the facility setting, including observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home or custodial care and the home setting.
• A major overhaul of the MDM documentation guidelines to emphasize complexity of the conditions being addressed in place of the number of diagnoses reported.

Read more details and find out how you can make your voice heard on these proposed changes at the Part B News blog.

Source: DecisionHealth (3-12-19)

Not Otherwise Classified (NOC) codes are used for services that do not have an existing CPT code that accurately identifies the service or procedure performed. Services billed under NOC codes will be denied as billing errors if codes describing the services are available. Wisconsin Physicians Service (WPS) Government Health Administrators (GHA) has recognized a reoccurring issue with NOC code descriptions. A large number of claims are being submitted with NOC codes, with missing or inadequate descriptions of the provided services.

NOC services, drugs, and biologicals can be correctly reimbursed by the WPS GHA only if providers indicate the following in the 2400/SV101-7 data element or Item 19 of the CMS 1500 form:

• A complete description of services performed. The description must have enough information for the reviewer to adequately determine coverage and compare pricing for similar services.
• The name of the drug/biologic, dosage, and method of administration.

Examples of good descriptions:

• Stab Phlebectomy of Varicose Veins 1 Extremity 6 Stab Incisions
• Arthroscopic Decompression of the Suprascapular Nerve
• Injection, Factor VIII FC Fusion (Recombinant), per IU: 25,000 units

Examples of inadequate descriptions:

• Not Otherwise Classified
• Biologic Injection
• Drug Administered

Providers should list one unit of service for the NOC code in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. NOC drugs and biologicals should not be quantity-billed, even if multiple units are provided. Narrative information is used to determine the payment for these codes. Documentation submitted with a claim must also support the described service. Claims without adequate descriptions and units of service may be rejected or denied.

Contact Yeo & Yeo Medical Billing & Consulting’s Certified Professional Coders for assistance with diagnostic or procedural coding.

Source:WPS Government Health Administrators

The Qualified Medicare Beneficiary (QMB) program provides help with Medicare premiums and cost-sharing for enrolled individuals. More than one out of eight people with Medicare are in the QMB. Medical providers are prohibited by federal law from billing people in the QMB program for Medicare deductibles, coinsurance, or copays. Providers may bill state Medicaid programs for those costs. Providers are subject to sanctions if they inappropriately bill those enrolled in the QMB program. Therefore, it is important for clinicians to implement processes to ensure that they comply with QMB billing requirements.

Providers should regularly identify the QMB status of Medicare beneficiaries in their care before billing for services. Medicare provides several resources to aid clinicians in this process.

• HIPAA Eligibility Transaction System (HETS) – This application allows providers to check updated Medicare beneficiary eligibility to prepare claims and bill services appropriately.
• Medicare Remittance Advice (RA) – Providers should check their Medicare RA. The Centers for Medicare & Medicaid Services (CMS) has reintroduced the QMB information on the remittance advice.
• Michigan Beneficiary Eligibility Verification – Providers should also check state automated Medicaid eligibility verification systems.

Billing errors occur and should be corrected as soon as possible. If a QMB participant is incorrectly billed, the charges should be recalled and all invalid charges paid should be refunded.

At Yeo & Yeo Medical Billing & Consulting, we help our clients bill beneficiaries correctly for services and ensure that their practices comply with QMB billing requirements. Please contact Yeo & Yeo Medical Billing & Consulting with questions.

The Merit-based Incentive Payment System (MIPS) is a program through which participating providers are evaluated and rewarded for improvement based on their performance in four categories. Performance is measured through data reported in four areas:

1. Quality – 45%
2. Promoting Interoperability – 25%
3. Cost – 15%
4. Improvement Activities – 15%

The weighted scores in these categories are combined to determine the comprehensive assessment score. Participating providers can submit data for the 2018 performance year until April 2, 2019, at 8:00 p.m.

The MIPS performance period for 2019 is from January 1, 2019, to December 31, 2019. Data must be collected for the full year for the Cost and Quality categories. For the Improvement Activities and Promoting Interoperability categories, data must be collected for at least a consecutive 90-day period.

Data for 2019 should be submitted to MIPS by the March 31, 2020, deadline to receive a positive, negative, or neutral payment adjustment in 2021.

The Centers for Medicare & Medicaid Services released videos to help MIPS participants with the process. The videos are intended to ease the burden of enrolling and participating in the program and cover a range of topics. Topics include how to register and set up a Quality Payment Program (QPP) account, how to add and approve authorized users for your practice, and how to connect your account to a group practice. Additional videos are available that show step-by-step instructions for how to view, submit, and manage your practice’s data.

For more information about MIPS and the QPP, visit:

• Yeo & Yeo Medical Billing & Consulting’s blog article: 2019 Quality Payment Program – Final Rule
• Quality Payment Program website: https://qpp.cms.gov
• Quality Payment Program video series: MIPS Video Resources

MGMA groups came together to write to the Centers for Medicare & Medicaid Services (CMS), asking them to extend the application deadline for accountable care organizations (ACOs) that wish to participate in the Medicare Shared Savings Program (MSSP) beginning July 1, 2019.

The CMS announced in December that the applications would be due on February 19, 2019. The letter from the MGMA requests that the application deadline be extended to March 29, 2019. The MGMA groups are concerned that the final rule for the program, which was published on December 31, 2018, is complex and that applicants are still familiarizing themselves with how they can successfully participate in the program.

They argue that additional time is necessary for ACOs to evaluate their options and complete the application’s requirements. ACOs are not always a single provider, but often are large physician groups, hospitals, and nursing facilities. Large practices like this are struggling to meet the February 19 deadline because they must have several boards sign on to finalize applications. The MGMA groups believe it is likely that the time-crunch will cause program participation to suffer.

The MGMA groups understand that the CMS must work within a timeline, but they express a desire for the MSSP to be sustained long-term and are concerned that the deadline will affect this.

See the letter written by the MGMA coalition. Yeo & Yeo Medical Billing & Consulting will follow this issue and communicate new developments.

The Centers for Medicare and Medicaid (CMS) released two new voluntary payment models for Medicare Advantage and/or Medicare Part D plans to further the value-based payment agenda. Both will run from 2020 through 2024.

Updated VBID

The first model is an updated version of the Value-Based Insurance Design (VBID) model. To reduce Medicare expenditures, increase the quality of care for Medicare beneficiaries, and improve efficiency, the CMS is testing this VBID model. This updated model extends access to Medicare Advantage (MA) plans to all 50 states. The eligible plan types are expanded to include Regional Preferred Provider Organizations and all Special Needs Plans (Chronic Condition SNPs, Dual Eligible SNPs, and Institutional SNPs).

The application period for 2020 is open now through March 1, 2019. Eligible clinicians can apply to test one or more of the new interventions:

• Value-Based Insurance Design by Condition, Socioeconomic Status, or both
• Medicare Advantage and Part D Rewards and Incentives Programs
• Telehealth Networks
• Wellness and Health Care Planning

Part D Payment Modernization

The second model is called Part D Payment Modernization. Patients, providers, and plans that choose drugs with lower price lists receive incentives through this five-year model. This model is created to test the revised Part D program and incentives on all Part D prescription drug spending and beneficiary costs. It is hoped that this model will reduce Medicare expenditures while maintaining quality care. Prescription Drug Plans and Medicare Advantage-Prescription Drug Plans are eligible. At this time, the application is open only for the calendar year 2020. However, the CMS may offer more application periods in the future depending on the success of the model.

For more information about these new payment models, visit:

MA Value-Based Insurance Design Model

Part D Payment Modernization Model

The Medicare Learning Network has released an article reiterating current Medicare policy. This information concentrates on the date(s) of service to submit when billing for these services. For those providing the services included in the document linked below, please take advantage of the information available and visit the Centers for Medicare & Medicaid Services website. 

View the Guidance on Coding and Billing Date of Service on Professional Claims. 

2019 will be another busy year in healthcare. Highlighted below are ten laws and regulations that will be critical for medical practices in the new year.

1. Participation in voluntary Medicare alternative payment models (APMs) has been relatively static in recent years. Secretary Azar and the Department of Health and Human Services (HHS) are looking to increase participation in risk-based APMs by making performance-based risk a mandatory component of new APMs in 2019.
   
   
2. The Merit-based Incentive Payment System (MIPS) stakes are raised in 2019. MIPS performance determines if clinicians receive a positive or negative payment adjustment of up to 7 percent in the 2021 payment year. For more information on what’s new with MIPS in 2019, see this article: 2019 Quality Payment Program – Final Rule.
   
   
3. HHS has promised to review the Stark Law and Anti-Kickback Statute and other such rules against fraud and abuse. It can be expected that rules to expand exceptions and protect value-based arrangements will be proposed in 2019, though influential reform will likely require the involvement of Congress. These updated rules will benefit providers willing to take performance-based risks.
   
   
4. Legislators will likely continue their efforts to reduce regulatory burdens on medical practices participating in government healthcare programs this year. The “Patients Over Paperwork” initiative by the Centers for Medicare & Medicaid Services exemplifies the intention to increase quality patient-focused care. The promised regulatory relief has been moderate at best, thus far, according to a poll of Medical Group Management Association members. However, this issue remains high priority going into 2019.
   
   
5. Further anticipated efforts for 2019 include those to empower patients by giving them improved access to healthcare cost information. This will reduce the surprise and sticker shock of receiving hospital bills that has received media attention in the past.
   
   
6. The requirements of the 21^st Century Cures Act are expected to be met when the Office of the National Coordinator for Health Information Technology (ONC) releases regulations to improve data sharing between healthcare entities. The goal is to develop a framework that allows the movement of data between health information exchange entities. This includes specifications for the use of apps to efficiently and securely move administrative and clinical data between providers and patients via their Electronic Health Records.
   
   
7. HIPAA enforcement is likely to increase audits and fines in 2019. Medical practices are targets for cybersecurity attacks because of the patient, clinical, and financial data they possess. Many times medical practices do not have adequate protection against such attacks. Comprehensive risk assessments highlighting weak areas should be done to protect data. Yeo & Yeo Technology has experience in conducting these Security Risk Assessments (SRAs) for healthcare practices. Contact YYTECH with questions or to schedule an SRA for your practice. YYTECH Security Risk Assessment.
   
   
8. Congress is looking to reduce Medicare drug prices in 2019. One proposal seeks to implement a new International Price Index to lower the price of physician-administered drugs in Part B. It also proposes to introduce new vendors to supply drugs to practices and set a flat fee for drug administration cost. CMS would like to increase the flexibility of Part D drug plans to negotiate prices in protected classes.
   
   
9. Continued efforts will be made to equalize Medicare payments for the same services across clinical sites. This policy was expanded in 2018 by reducing payment for clinic visits at hospital outpatient departments. Site-neutral payments are supposed to save patients and the government money as well as increase market competition.
   
   
10. “Medicare for all” was a key platform for many in the 2018 elections. Though it is unlikely that any major health reform bill will be passed soon, universal healthcare will most likely be a point of debate as presidential contenders campaign for the 2020 primaries.

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Claims with dates of services on or after 1/01/16 for professional non-physician providers (Psychologists, Social workers, Marriage/Family Therapists, and Professional Counselors) were paying incorrect rates. This has been corrected in CHAMPS as of the December 14, 2018 release to allow claims to properly pay the correct rates, per MSA 15-44 and MSA 15-14.

MDHHS will adjust the impacted claims beginning on pay cycle date 1/17/2019 until complete. The claims can be identified with claim note “Correcting overpayments for non-physicians”.

Providers with further questions can contact provider support by phone 1-800-292-2550 or by email ProviderSupport@Michigan.gov. 

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Effective immediately, there are some notable changes in the statute that governs Medicaid subrogation. The changes address the shortcomings in the old law and provide clarity to the process where possible. These changes include: 

• Defining the process by which “notice to the department” is accomplished. The new statute requires that notice be provided to MDHHS (and any associated Medicaid managed care plan) within 30 days of filing a case and that attorneys certify this notice on the SCAO summons form. A copy of this form, the complaint and all other documents filed with the complaint must be provided to MDHHS and the contracted health plan, if applicable. This change provides a new framework under which attorneys’ offices demonstrate their intent to comply with Medicaid’s right to recover its expenses. (We are working with SCAO on the form change and expect it to be available by February 1.)
• Defining what information must be provided to MDHHS (or managed care plan) at the time of settlement in order for Medicaid to determine its recovery.
• Providing for a specific penalty for each failure to provide notice. An attorney who knowingly fails to notify the department or managed care plan is subject to a $1,000 civil fine.
• Requiring prompt responses from the department and managed care plans or their vendors by specifying that the department and plans must provide detailed responses within 30 days. Failure to provide this information within 30 days releases counsel’s obligation to protect Medicaid’s interest. This new language addresses concerns with poor customer service and unnecessary delays in proceedings due to slow response times.

Lastly, to expedite the process, we are eliminating our internal requirement that attorneys must provide a HIPAA form for casualty subrogation purposes .

We believe these changes add certainty and clarity into the notice process and worked on the language with the Michigan Association for Justice to ensure that your interests were represented. MDHHS values and respects our collaboration in this process and will continue to provide excellent customer service, individualized attention to each case, and reasonable compromises to assist attorneys in your attempts to navigate this process. Medicaid will continue to honor the “50-50” distribution with members and negotiate recoveries with counsel in good faith depending on the terms of the settlement. Please contact us with questions or concerns and we’ll work to address them with you.